Provider Demographics
NPI:1922115906
Name:OLIVER, GINNIE M (MOMT, PT)
Entity Type:Individual
Prefix:
First Name:GINNIE
Middle Name:M
Last Name:OLIVER
Suffix:
Gender:F
Credentials:MOMT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40589 MORNING STAR RD
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-9470
Mailing Address - Country:US
Mailing Address - Phone:907-223-1181
Mailing Address - Fax:
Practice Address - Street 1:4141 PENNOCK ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7223
Practice Address - Country:US
Practice Address - Phone:907-235-3410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA765225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT0710Medicaid
AKPT0710Medicaid