Provider Demographics
NPI:1154306413
Name:OLIVAS, CARLOS ANTONIO (ATC)
Entity Type:Individual
Prefix:MR
First Name:CARLOS
Middle Name:ANTONIO
Last Name:OLIVAS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9505 ELVIN AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2913
Mailing Address - Country:US
Mailing Address - Phone:505-681-9004
Mailing Address - Fax:
Practice Address - Street 1:9505 ELVIN AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2913
Practice Address - Country:US
Practice Address - Phone:505-681-9004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
FL15052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer