Provider Demographics
NPI:1669754958
Name:OLIVER, KRISTIE (PA)
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:OLIVER
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 1:260 CREST RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-9503
Mailing Address - Country:US
Mailing Address - Phone:802-524-8911
Mailing Address - Fax:
Practice Address - Street 1:260 CREST RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAINT ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478-9503
Practice Address - Country:US
Practice Address - Phone:802-524-8911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031181363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1102040OtherNCCPA
VT055.0031181OtherVT STATE LICENSE
CAPA21832OtherSTATE OF CALIFORNIA- PA LICENSE