Provider Demographics
NPI:1407334832
Name:NOLAN, MICHAEL GRAEME (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GRAEME
Last Name:NOLAN
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3034 DONNELL RIDGE RD APT 104
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-8684
Mailing Address - Country:US
Mailing Address - Phone:816-820-3427
Mailing Address - Fax:
Practice Address - Street 1:201 DONAGHEY AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72035-5001
Practice Address - Country:US
Practice Address - Phone:501-450-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR8272255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer