Provider Demographics
NPI:1821044603
Name:OLIVA, LAURAJEAN (RPAC)
Entity Type:Individual
Prefix:
First Name:LAURAJEAN
Middle Name:
Last Name:OLIVA
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-0725
Mailing Address - Country:US
Mailing Address - Phone:607-433-6314
Mailing Address - Fax:607-433-6330
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-433-6314
Practice Address - Fax:607-433-6330
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001045363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01271741Medicaid
NYR54823Medicare UPIN
NY01271741Medicaid