Provider Demographics
NPI:1689275000
Name:NOLAN, JACOB JOHNSTON (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:JOHNSTON
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 1:2824 ELKHART RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-1014
Mailing Address - Country:US
Mailing Address - Phone:574-825-3888
Mailing Address - Fax:
Practice Address - Street 1:2824 ELKHART RD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-1014
Practice Address - Country:US
Practice Address - Phone:574-535-1700
Practice Address - Fax:574-535-1799
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002996A363A00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10002996AOtherPA-C LICENSE NUMBER