Provider Demographics
NPI:1245552074
Name:BLUME, OLIVIA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ROSE
Last Name:BLUME
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 1:13423 N REGULATION DR
Mailing Address - Street 2:
Mailing Address - City:ORO VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85755-6876
Mailing Address - Country:US
Mailing Address - Phone:520-293-6862
Mailing Address - Fax:520-887-0160
Practice Address - Street 1:2550 N THUNDERBIRD CIR
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-1214
Practice Address - Country:US
Practice Address - Phone:520-694-6110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-21
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant