Provider Demographics
NPI:1609652494
Name:WEASE, OLIVIA RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RAE
Last Name:WEASE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-1267
Mailing Address - Country:US
Mailing Address - Phone:336-783-8911
Mailing Address - Fax:336-786-3752
Practice Address - Street 1:1016 S SOUTH ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030
Practice Address - Country:US
Practice Address - Phone:336-783-8900
Practice Address - Fax:336-783-3417
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-13585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant