Provider Demographics
NPI:1629389028
Name:DYER, NOLAN RAY
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:RAY
Last Name:DYER
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 1:4453 S DAVIDSON DR
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6785
Mailing Address - Country:US
Mailing Address - Phone:816-373-6603
Mailing Address - Fax:
Practice Address - Street 1:6124 RAYTOWN RD
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-4007
Practice Address - Country:US
Practice Address - Phone:816-353-2559
Practice Address - Fax:816-743-0012
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO102707225100000X
KS11-02684225100000X
AZ3876225100000X
CA22719225100000X
FL20963225100000X
NV1093225100000X
TX1150938225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist