Healthcare Provider Details

I. General information

NPI: 1184179160
Provider Name (Legal Business Name): DEANNA NOLAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2016
Last Update Date: 07/03/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4421 NE ST JOHNS RD STE F
VANCOUVER WA
98661-2573
US

IV. Provider business mailing address

2052 SE HAWTHORNE BLVD APT 105
PORTLAND OR
97214-3891
US

V. Phone/Fax

Practice location:
  • Phone: 360-695-9922
  • Fax:
Mailing address:
  • Phone: 716-430-1695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number24385
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60683787
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: