Healthcare Provider Details

I. General information

NPI: 1205570629
Provider Name (Legal Business Name): NICHOLAS ANDREW NOLAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 E MAYO BLVD
PHOENIX AZ
85054-4502
US

IV. Provider business mailing address

12 HILLENDALE CT
HUNTINGTON WV
25705-3745
US

V. Phone/Fax

Practice location:
  • Phone: 480-342-2000
  • Fax:
Mailing address:
  • Phone: 304-521-3244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR79412
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: