1578564597 NPI number — HEIDI W NOLAN PA-C

Table of content: HEIDI W NOLAN PA-C (NPI 1578564597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578564597 NPI number — HEIDI W NOLAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOLAN
Provider First Name:
HEIDI
Provider Middle Name:
W
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578564597
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
874 HOWARD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06519-1106
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-688-8200
Provider Business Mailing Address Fax Number:
203-688-8204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
874 HOWARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06519-1106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-688-8200
Provider Business Practice Location Address Fax Number:
203-688-8204
Provider Enumeration Date:
08/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  000279 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 970013793 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 061561581 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 008037010 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 279001 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P2364340 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 290000279CT03 . This is a "ANTHEM BC/BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0Q2938 . This is a "HEALTH NET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 368792 . This is a "WELLCARE OF CT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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