Provider Demographics
NPI:1457352247
Name:OLIVARES, ODILIA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ODILIA
Middle Name:
Last Name:OLIVARES
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 1:1172 N MACLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-1328
Mailing Address - Country:US
Mailing Address - Phone:818-898-1388
Mailing Address - Fax:818-365-4031
Practice Address - Street 1:12540 PIERCE ST
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1701
Practice Address - Country:US
Practice Address - Phone:818-897-2193
Practice Address - Fax:818-899-3864
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q08831Medicare UPIN