Provider Demographics
NPI:1386036739
Name:COTA, OLIVIA NICOLE (AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:NICOLE
Last Name:COTA
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:MRS
Other - First Name:OLIVIA
Other - Middle Name:NICOLE
Other - Last Name:LUSTRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGPCNP-BC
Mailing Address - Street 1:220 COMMERCE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-1323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 COMMERCE
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92602-1323
Practice Address - Country:US
Practice Address - Phone:714-921-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001600363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner