Provider Demographics
NPI:1366040099
Name:ALLAN DOUGLAS NANNEY III MD LLC
Entity type:Organization
Organization Name:ALLAN DOUGLAS NANNEY III MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TRIPP
Authorized Official - Middle Name:
Authorized Official - Last Name:NANNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-519-9162
Mailing Address - Street 1:6653 LOOKOUT RD # A103
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-3362
Mailing Address - Country:US
Mailing Address - Phone:704-519-9162
Mailing Address - Fax:
Practice Address - Street 1:259 BEACON LITE RD STE 103
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-9110
Practice Address - Country:US
Practice Address - Phone:704-519-9162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty