Healthcare Provider Details

I. General information

NPI: 1285491522
Provider Name (Legal Business Name): MR. NOAH JORDAN DOOLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 NE COLORADO ST
PULLMAN WA
99163
US

IV. Provider business mailing address

1890 NE MERMAN DR APT A202
PULLMAN WA
99163-5093
US

V. Phone/Fax

Practice location:
  • Phone: 800-462-6847
  • Fax:
Mailing address:
  • Phone: 206-305-4951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number321593
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number321593
License Number StateWA

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: