Healthcare Provider Details

I. General information

NPI: 1770990848
Provider Name (Legal Business Name): PATRICK OLISE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE STE 160
MARIETTA GA
30060-1160
US

IV. Provider business mailing address

PO BOX 844088
DALLAS TX
75284-4088
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-1372
  • Fax:
Mailing address:
  • Phone: 505-609-2258
  • Fax: 505-609-2259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2016-0024
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7242
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: