Provider Demographics
NPI:1912454067
Name:HOUCK, OLIVIA ROSE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:OLIVIA
Middle Name:ROSE
Last Name:HOUCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:OLIVIA
Other - Middle Name:ROSE
Other - Last Name:LEAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1006 NEW MOODY LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9122
Mailing Address - Country:US
Mailing Address - Phone:502-222-0008
Mailing Address - Fax:502-222-0029
Practice Address - Street 1:1006 NEW MOODY LN
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9122
Practice Address - Country:US
Practice Address - Phone:502-222-0008
Practice Address - Fax:502-222-0029
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant