Healthcare Provider Details

I. General information

NPI: 1639699457
Provider Name (Legal Business Name): EMILY MARIE NOVICKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 W KINNICKINNIC RIVER PKWY STE 507
MILWAUKEE WI
53215-3660
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-3780
  • Fax:
Mailing address:
  • Phone: 414-646-3780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4014-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: