Provider Demographics
NPI:1598486102
Name:MCCOURT, NOLAN (PA-C)
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:
Last Name:MCCOURT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 JERICHO VALLEY WAY
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803-2788
Mailing Address - Country:US
Mailing Address - Phone:262-758-4501
Mailing Address - Fax:
Practice Address - Street 1:441 S ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-7510
Practice Address - Country:US
Practice Address - Phone:865-685-0767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5087363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical