Provider Demographics
NPI:1558607507
Name:WESTCOTT, OLIVIA ALEXIS (PA-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ALEXIS
Last Name:WESTCOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:ALEXIS
Other - Last Name:KENYON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:304 S MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6218
Mailing Address - Country:US
Mailing Address - Phone:575-226-3023
Mailing Address - Fax:575-226-3024
Practice Address - Street 1:304 S MAIN AVE
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6218
Practice Address - Country:US
Practice Address - Phone:575-226-3023
Practice Address - Fax:575-226-3024
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107007363A00000X
WAPA60376448363A00000X
NMPA2015-0012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0F2HOtherBCBS
FLY0F2HOtherBCBS
FL0626040002Medicare NSC