Provider Demographics
NPI:1215035506
Name:C OLLEY, HARVEY (PA)
Entity Type:Individual
Prefix:
First Name:HARVEY
Middle Name:
Last Name:C OLLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-0578
Mailing Address - Country:US
Mailing Address - Phone:704-923-0446
Mailing Address - Fax:704-923-8319
Practice Address - Street 1:107 N SUMMEY ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:NC
Practice Address - Zip Code:28034-1824
Practice Address - Country:US
Practice Address - Phone:704-923-0446
Practice Address - Fax:704-923-8319
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP33082Medicare UPIN