Provider Demographics
NPI:1770220485
Name:NOLAN, BRENT JOHN (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:JOHN
Last Name:NOLAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 4TH ST STOP 8143
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-8143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST STOP 8143
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-8143
Practice Address - Country:US
Practice Address - Phone:806-743-6130
Practice Address - Fax:806-743-1421
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-14
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program