Healthcare Provider Details

I. General information

NPI: 1215677653
Provider Name (Legal Business Name): JOHNNY NOLAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11211 SE 82ND AVE STE Z
HAPPY VALLEY OR
97086-7669
US

IV. Provider business mailing address

502 W HIGHLAND BLVD
INVERNESS FL
34452-4720
US

V. Phone/Fax

Practice location:
  • Phone: 971-432-7555
  • Fax:
Mailing address:
  • Phone: 352-726-1551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO226572
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: