MEDICARE: MICHAEL JOSEPEH NOLAN ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2011026856	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2000000863	OTHER		NATABOC
2	2011026856	OTHER	MO	DIVISION OF PROFRESSIONAL REGULATION

General Provider Information

NPI Number	:	1144552233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL JOSEPEH NOLAN ATC

Provider Business Mailing Address
First Line	:	209 S KINGSHIGHWAY ST
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-1695
Country	:	US
Telephone Number	:	636-339-6951
Fax Number	:

Provider Business Practice Location Address
First Line	:	2532 SIMS AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63114-3204
Country	:	US
Telephone Number	:	314-882-7665
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2010
Last Update Date	:	12/13/2023

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