Provider Demographics
NPI:1811510761
Name:LUST, OLIVIA NICOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:NICOLE
Last Name:LUST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1447 RUMBAUGH CIR
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-3009
Mailing Address - Country:US
Mailing Address - Phone:330-635-2782
Mailing Address - Fax:
Practice Address - Street 1:5225 CLEVELAND RD STE B
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-5541
Practice Address - Country:US
Practice Address - Phone:300-845-4151
Practice Address - Fax:330-845-4152
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH50.006500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program