MEDICARE: ALISA NOLA O.D.

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	152W00000X	Optometrist	3386	MN
2	152WV0400X	Vision Therapy Optometrist	8861T	TX
3	152W00000X	Optometrist	1987	KS

General Provider Information

NPI Number	:	1386059053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALISA NOLA O.D.

Provider Business Mailing Address
First Line	:	6 LAKEWOOD DR
Second Line	:
City	:	GODDARD
State	:	KS
Zip	:	67052-9256
Country	:	US
Telephone Number	:	316-512-1171
Fax Number	:

Provider Business Practice Location Address
First Line	:	7700 E KELLOGG DR
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67207-1772
Country	:	US
Telephone Number	:	316-685-1802
Fax Number	:

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

Provider Enumeration Date	:	06/21/2014
Last Update Date	:	10/27/2020

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