Provider Demographics
NPI:1164145082
Name:MADDOX, OLIVIA PAIGE (PA)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:PAIGE
Last Name:MADDOX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:PAIGE
Other - Last Name:ROTENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:408 E 8TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2957
Mailing Address - Country:US
Mailing Address - Phone:612-810-6643
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2111363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant