Provider Demographics
NPI:1588678429
Name:NOLZ, JASON P (OD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:NOLZ
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W DL INGRAM AVE
Mailing Address - Street 2:CANNON AFB
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88103-5014
Mailing Address - Country:US
Mailing Address - Phone:575-784-6608
Mailing Address - Fax:
Practice Address - Street 1:208 W DL INGRAM AVE
Practice Address - Street 2:
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103-5014
Practice Address - Country:US
Practice Address - Phone:575-784-6608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT627152W00000X
CO2180152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist