Provider Demographics
NPI:1306957105
Name:NOLAN, JOHN A (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:NOLAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:599 BLACK MOUNTAIN RD W
Mailing Address - Street 2:
Mailing Address - City:DUNLAP
Mailing Address - State:TN
Mailing Address - Zip Code:37327-6731
Mailing Address - Country:US
Mailing Address - Phone:423-949-8492
Mailing Address - Fax:
Practice Address - Street 1:5000 ALPHA LN
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4054
Practice Address - Country:US
Practice Address - Phone:423-870-1662
Practice Address - Fax:423-877-4845
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000000612363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3666970Medicare ID - Type Unspecified
S43124Medicare UPIN