Healthcare Provider Details

I. General information

NPI: 1962873059
Provider Name (Legal Business Name): CELESTE OLMOS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10210 N 92ND ST STE 202
SCOTTSDALE AZ
85258-4524
US

IV. Provider business mailing address

10210 N 92ND ST STE 202
SCOTTSDALE AZ
85258-4524
US

V. Phone/Fax

Practice location:
  • Phone: 480-882-7490
  • Fax:
Mailing address:
  • Phone: 480-882-7490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6149
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: