Provider Demographics
NPI:1891072005
Name:OLAVARRIA, VICTOR M JR (CRNA)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:M
Last Name:OLAVARRIA
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18699 W LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2526
Mailing Address - Country:US
Mailing Address - Phone:262-960-7635
Mailing Address - Fax:
Practice Address - Street 1:5900 N MULLIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5334
Practice Address - Country:US
Practice Address - Phone:770-826-5045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0000000367500000X
WICRNA1019367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100019901Medicaid