Provider Demographics
NPI:1417213448
Name:NOLAN, THEA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:THEA
Middle Name:MARIE
Last Name:NOLAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:THEA
Other - Middle Name:MARIE
Other - Last Name:POMPONIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 415348
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5348
Mailing Address - Country:US
Mailing Address - Phone:800-225-8885
Mailing Address - Fax:508-334-1977
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-1000
Practice Address - Fax:775-442-5891
Is Sole Proprietor?:No
Enumeration Date:2012-04-04
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110123013AMedicaid