Provider Demographics
NPI:1144467119
Name:DEATHERAGE, NOLAN (DC)
Entity type:Individual
Prefix:
First Name:NOLAN
Middle Name:
Last Name:DEATHERAGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 SUPERMALL WAY STE 1269
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-6535
Mailing Address - Country:US
Mailing Address - Phone:253-269-0261
Mailing Address - Fax:
Practice Address - Street 1:1101 SUPERMALL WAY STE 1269
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-6535
Practice Address - Country:US
Practice Address - Phone:253-269-0261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60040685111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor