Healthcare Provider Details

I. General information

NPI: 1245552074
Provider Name (Legal Business Name): OLIVIA ROSE BLUME PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2010
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2426 N MERRITT CREEK LOOP STE A
COEUR D ALENE ID
83814-4961
US

IV. Provider business mailing address

1296 E HOFFMAN AVE
COEUR D ALENE ID
83815-7324
US

V. Phone/Fax

Practice location:
  • Phone: 208-819-2183
  • Fax: 208-209-6063
Mailing address:
  • Phone: 520-999-1598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61659218
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4441
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7971040
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: