Healthcare Provider Details

I. General information

NPI: 1144159765
Provider Name (Legal Business Name): NOLAN BASHORE PA-S3
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21498 ARBOR GLEN CT
BROADLANDS VA
20148-5070
US

IV. Provider business mailing address

21498 ARBOR GLEN CT
BROADLANDS VA
20148-5070
US

V. Phone/Fax

Practice location:
  • Phone: 571-577-7043
  • Fax:
Mailing address:
  • Phone: 571-577-7043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: