Provider Demographics
NPI:1417411190
Name:GREENWALD, OLIVIA BREE (PA)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:BREE
Last Name:GREENWALD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4511 PARK MARBELLA
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-2535
Mailing Address - Country:US
Mailing Address - Phone:818-264-6800
Mailing Address - Fax:
Practice Address - Street 1:444 S SAN VICENTE BLVD STE 901
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4174
Practice Address - Country:US
Practice Address - Phone:310-248-7330
Practice Address - Fax:310-248-7395
Is Sole Proprietor?:No
Enumeration Date:2019-01-26
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56493363A00000X
CAPA56493363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant