Provider Demographics
NPI:1801070974
Name:BILL D NOLEN PA
Entity type:Organization
Organization Name:BILL D NOLEN PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:D
Authorized Official - Last Name:NOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:979-242-5878
Mailing Address - Street 1:2 SAINT MARKS PL STE 112
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:TX
Mailing Address - Zip Code:78945-1256
Mailing Address - Country:US
Mailing Address - Phone:979-242-5878
Mailing Address - Fax:979-242-5818
Practice Address - Street 1:2 SAINT MARKS PL STE 112
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:TX
Practice Address - Zip Code:78945-1256
Practice Address - Country:US
Practice Address - Phone:979-242-5878
Practice Address - Fax:979-242-5818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085122201Medicaid
TX085122201Medicaid