=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740843986
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS JAMES NOVAK DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2019
-----------------------------------------------------
Last Update Date | 06/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7405 RENNER RD
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66217-9414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-588-1227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3551 ROGER BROOKE DR
-----------------------------------------------------
City | FORT SAM HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-897-7961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 0102207138
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 0102207138
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 05-51224
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------