Healthcare Provider Details

I. General information

NPI: 1417410192
Provider Name (Legal Business Name): THOMAS OLESKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 MARINER HEALTH WAY STE 213
SAINT AUGUSTINE FL
32086-3251
US

IV. Provider business mailing address

105 MARINER HEALTH WAY STE 213
SAINT AUGUSTINE FL
32086-3251
US

V. Phone/Fax

Practice location:
  • Phone: 904-217-4259
  • Fax: 904-217-4251
Mailing address:
  • Phone: 904-217-4259
  • Fax: 904-217-4251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number042779
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT35117
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: