MEDICARE: HARRY JAMES OLIVELLA PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA02107	TX

General Provider Information

NPI Number	:	1265489322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HARRY JAMES OLIVELLA PAC

Provider Business Mailing Address
First Line	:	PO BOX 2701
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75606-2701
Country	:	US
Telephone Number	:	903-315-5704
Fax Number	:	903-315-2907

Provider Business Practice Location Address
First Line	:	404 N KAUFMAN ST
Second Line	:
City	:	LINDEN
State	:	TX
Zip	:	75563-5234
Country	:	US
Telephone Number	:	903-756-5561
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	03/04/2009

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