Basic Information
| Provider Information | |||||||||
| NPI: | 1366421356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NOLAN | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1230 E MAIN ST | ||||||||
| Address2: | PO BOX 8674 MANKATO CLINIC LTD | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1230 E MAIN STREET | ||||||||
| Address2: | MANKATO CLINIC @ MAIN STREET | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 23067 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 41084933956001C050 | 01 | CHAMPUS | OTHER | 41485NO | 01 | MN | BCBS | OTHER | 1202178 | 01 | MN | MEDICA | OTHER | 895687 | 01 | MN | AMERICAS PPO | OTHER | HP25857 | 01 | MN | HEALTH PARTNERS | OTHER | 938241 | 05 | IA | MEDICAID | 112538 | 01 | MN | UCARE | OTHER | NA2951023848 | 01 | MN | PREFERRED ONE | OTHER |