Provider Demographics
NPI:1063043982
Name:OLIVERA, JOSE DANIEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:DANIEL
Last Name:OLIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13021 27TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-4313
Mailing Address - Country:US
Mailing Address - Phone:423-309-4962
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE STE 100
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-8450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAP61034008367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered