Healthcare Provider Details

I. General information

NPI: 1669464392
Provider Name (Legal Business Name): DAVID EZRA NOLAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 FAIR GROUNDS ROAD
HAMILTON MT
59840
US

IV. Provider business mailing address

312 FAIR GROUNDS ROAD
HAMILTON MT
59840
US

V. Phone/Fax

Practice location:
  • Phone: 406-361-7680
  • Fax: 406-363-4060
Mailing address:
  • Phone: 406-361-7680
  • Fax: 406-363-4060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0292
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0292
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0292
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: