Healthcare Provider Details

I. General information

NPI: 1104159235
Provider Name (Legal Business Name): BEN OLWE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8515 N MITCHELL AVE
TAMPA FL
33604-1658
US

IV. Provider business mailing address

1105 E KENNEDY BLVD
TAMPA FL
33602-3511
US

V. Phone/Fax

Practice location:
  • Phone: 813-307-8015
  • Fax: 813-276-2999
Mailing address:
  • Phone: 813-307-8015
  • Fax: 813-276-2999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 9100268
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: