Provider Demographics
NPI:1396921649
Name:OLVERA, ANA PATRISIA (COTA)
Entity type:Individual
Prefix:MISS
First Name:ANA
Middle Name:PATRISIA
Last Name:OLVERA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002B FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-3858
Mailing Address - Country:US
Mailing Address - Phone:903-445-2211
Mailing Address - Fax:
Practice Address - Street 1:5609 DONNYBROOK AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-6111
Practice Address - Country:US
Practice Address - Phone:903-561-2808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210111208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1100190-02Medicaid
TX1100190-02Medicaid