Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | K2766 | TX |
NPI | 1043336381 |
---|---|
Provider Name | Jacob John Novak |
First Address | Fort Worth, TX 76161-0214 |
Second Address | Flower Mound, TX 75022-4839 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G55568 | (02) | TX |
K2766 | STATE LICENSE (01) | TX |