Provider Demographics
NPI:1598478588
Name:GONCERZ, OLIVIA NICOLE
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NICOLE
Last Name:GONCERZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 UNIVERSITY DR STE 300
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1873
Mailing Address - Country:US
Mailing Address - Phone:610-772-6889
Mailing Address - Fax:
Practice Address - Street 1:701 N CLAYTON ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-3165
Practice Address - Country:US
Practice Address - Phone:302-954-5157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064964363A00000X
PAOA006644363A00000X
DEC5-0011977363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant