Provider Demographics
NPI:1386664787
Name:NOLAN, MICHAEL J (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:NOLAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:56 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1253
Mailing Address - Country:US
Mailing Address - Phone:203-709-6360
Mailing Address - Fax:203-709-5118
Practice Address - Street 1:56 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1253
Practice Address - Country:US
Practice Address - Phone:203-709-6360
Practice Address - Fax:203-709-5118
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001644363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ47081Medicare UPIN