Provider Demographics
NPI:1629329099
Name:OLIVARES, MONIQUE (PA)
Entity Type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:
Last Name:OLIVARES
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 1:911 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0385
Mailing Address - Country:US
Mailing Address - Phone:212-772-7242
Mailing Address - Fax:212-517-9566
Practice Address - Street 1:911 PARK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-0385
Practice Address - Country:US
Practice Address - Phone:212-772-7242
Practice Address - Fax:212-517-9566
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1105800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant