Provider Demographics
NPI:1669663076
Name:NOLL, ERIC P (DPT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:P
Last Name:NOLL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11414 W CENTER RD
Mailing Address - Street 2:STE 242
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4487
Mailing Address - Country:US
Mailing Address - Phone:402-991-7888
Mailing Address - Fax:
Practice Address - Street 1:12905 W DODGE RD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154-2145
Practice Address - Country:US
Practice Address - Phone:402-991-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1870208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1669663076OtherRENDERING PROVIDER ID
NE100250996-00Medicaid
NE277581OtherPERFORMING PROVIDER NUMBE
NE100250996-00Medicaid