Provider Demographics
NPI:1669464392
Name:NOLAN, DAVID EZRA (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:EZRA
Last Name:NOLAN
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 1:312 FAIR GROUNDS ROAD
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840
Mailing Address - Country:US
Mailing Address - Phone:406-361-7680
Mailing Address - Fax:406-363-4060
Practice Address - Street 1:312 FAIR GROUNDS ROAD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840
Practice Address - Country:US
Practice Address - Phone:406-361-7680
Practice Address - Fax:406-363-4060
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT0292363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4310345Medicaid
MT4310345Medicaid
MT011000207Medicare PIN
MTP53684Medicare UPIN
011000207Medicare PIN