Provider Demographics
NPI:1508430257
Name:HODGES, NOLAN
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:
Last Name:HODGES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3913 JACKSON LAKE RD NW
Mailing Address - Street 2:
Mailing Address - City:LAKEBAY
Mailing Address - State:WA
Mailing Address - Zip Code:98349-9733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9040A JACKSON AVE
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98431-9733
Practice Address - Country:US
Practice Address - Phone:425-583-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2023-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAA1614559702255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer