Provider Demographics
NPI:1013903426
Name:OLIVER, CARL GLENN (PA)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:GLENN
Last Name:OLIVER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 SUMTER ST
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-1734
Mailing Address - Country:US
Mailing Address - Phone:478-472-8178
Mailing Address - Fax:478-472-3289
Practice Address - Street 1:502 SUMTER ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1734
Practice Address - Country:US
Practice Address - Phone:478-472-8178
Practice Address - Fax:478-472-3289
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA04064363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA455252909AMedicaid
GA364910OtherWELLCARE
GA364910OtherWELLCARE
GA455252909AMedicaid