Healthcare Provider Details

I. General information

NPI: 1750188694
Provider Name (Legal Business Name): NICOLAS ANDRES OLMEDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 TEXAS WALK
GRAND JUNCTION CO
81501-3047
US

IV. Provider business mailing address

827 TEXAS WALK
GRAND JUNCTION CO
81501-3047
US

V. Phone/Fax

Practice location:
  • Phone: 571-425-8399
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: