Provider Demographics
NPI:1033418439
Name:OLIVE, TIMOTHY RAY (ARNP)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:RAY
Last Name:OLIVE
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2642
Mailing Address - Country:US
Mailing Address - Phone:918-647-7416
Mailing Address - Fax:918-647-3508
Practice Address - Street 1:2011 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2642
Practice Address - Country:US
Practice Address - Phone:918-647-7416
Practice Address - Fax:918-647-3508
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK77830363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK77830OtherNURSING LICENSE