Provider Demographics
NPI:1215401856
Name:BULL, OLIVIA HUNTINGTON (PA-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:HUNTINGTON
Last Name:BULL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9050 BIG RUN RD
Mailing Address - Street 2:
Mailing Address - City:GAMBIER
Mailing Address - State:OH
Mailing Address - Zip Code:43022-9626
Mailing Address - Country:US
Mailing Address - Phone:614-202-9685
Mailing Address - Fax:
Practice Address - Street 1:950 CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-2770
Practice Address - Country:US
Practice Address - Phone:203-932-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA004717363A00000X
PAMA060421363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical