Provider Demographics
NPI:1740385236
Name:OLIVA, MARY E (PA-C,)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:OLIVA
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 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-4401
Mailing Address - Fax:859-258-4418
Practice Address - Street 1:1221 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-258-4401
Practice Address - Fax:859-258-4418
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA636363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95001541Medicaid
KY37903705OtherMEDICAID LAB GROUP
KY4000501OtherMEDICARE LAB GROUP
CB5773OtherRR MEDICARE GROUP
P32487Medicare UPIN
KY95001541Medicaid