Provider Demographics
NPI:1366421356
Name:NOLAN, PETER S (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:S
Last Name:NOLAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E MAIN ST
Mailing Address - Street 2:PO BOX 8674 MANKATO CLINIC LTD
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN STREET
Practice Address - Street 2:MANKATO CLINIC @ MAIN STREET
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56002-8674
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23067208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
41084933956001C050OtherCHAMPUS
MN41485NOOtherBCBS
MN1202178OtherMEDICA
MN895687OtherAMERICAS PPO
MNHP25857OtherHEALTH PARTNERS
IA938241Medicaid
MN112538OtherUCARE
MNNA2951023848OtherPREFERRED ONE
MNHP25857OtherHEALTH PARTNERS