Provider Demographics
NPI:1750560801
Name:MCGLASSON, NOLAN JACOB (PA)
Entity type:Individual
Prefix:
First Name:NOLAN
Middle Name:JACOB
Last Name:MCGLASSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:866-273-5392
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:3900 KRESGE WAY STE 46
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4681
Practice Address - Country:US
Practice Address - Phone:502-899-3858
Practice Address - Fax:502-899-3878
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001647A363A00000X
KYTC819363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM54226082Medicare PIN