Provider Demographics
NPI:1376000547
Name:NOLAN, BRENDON (DPT)
Entity type:Individual
Prefix:MR
First Name:BRENDON
Middle Name:
Last Name:NOLAN
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 1:679 WHISKEY RD
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961-8352
Mailing Address - Country:US
Mailing Address - Phone:631-821-8090
Mailing Address - Fax:
Practice Address - Street 1:679 WHISKEY RD
Practice Address - Street 2:
Practice Address - City:RIDGE
Practice Address - State:NY
Practice Address - Zip Code:11961-8352
Practice Address - Country:US
Practice Address - Phone:631-821-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038336-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist