Provider Demographics
NPI:1700803616
Name:NOLAN, PHYLLIS CAROL (DO)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:CAROL
Last Name:NOLAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:CAROL
Other - Last Name:NOLAN-SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:100 S BLISS AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2512
Mailing Address - Country:US
Mailing Address - Phone:918-458-3360
Mailing Address - Fax:918-458-3511
Practice Address - Street 1:100 S BLISS AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2512
Practice Address - Country:US
Practice Address - Phone:918-458-3360
Practice Address - Fax:918-458-3511
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
8HZ05AMedicare ID - Type UnspecifiedMEDICARE PROVIDER# (WWH)
E16462Medicare UPIN