Provider Demographics
NPI:1669252250
Name:WIKA, OLIVIA (PA)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:WIKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2426 N MERRITT CREEK LOOP STE A
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4961
Mailing Address - Country:US
Mailing Address - Phone:208-819-2183
Mailing Address - Fax:
Practice Address - Street 1:2426 N MERRITT CREEK LOOP STE A
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4961
Practice Address - Country:US
Practice Address - Phone:208-819-2183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61455717363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty