Healthcare Provider Details

I. General information

NPI: 1477592137
Provider Name (Legal Business Name): THOMAS P NOLAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/25/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 N MELVIN ST
GIBSON IL
60936
US

IV. Provider business mailing address

20940 BRADFORD DR
MOKENA IL
60448-1470
US

V. Phone/Fax

Practice location:
  • Phone: 217-784-4251
  • Fax:
Mailing address:
  • Phone: 708-341-1369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28124135A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.001102
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: