Provider Demographics
NPI:1104121243
Name:NOLAN, SUSAN JANE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:JANE
Last Name:NOLAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6202
Mailing Address - Fax:239-437-8537
Practice Address - Street 1:22655 BAYSHORE RD STE 110
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-2005
Practice Address - Country:US
Practice Address - Phone:941-235-4900
Practice Address - Fax:941-235-4901
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105671363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004409300Medicaid