Provider Demographics
NPI:1417613282
Name:DEBELLIS, OLIVIA PATRICE (PA-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:PATRICE
Last Name:DEBELLIS
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-659-4777
Mailing Address - Fax:336-659-4798
Practice Address - Street 1:245 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1507
Practice Address - Country:US
Practice Address - Phone:336-659-4777
Practice Address - Fax:336-659-4798
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12882363A00000X
PAMA062993363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA062993OtherSTATE LICENSE