Healthcare Provider Details

I. General information

NPI: 1346961158
Provider Name (Legal Business Name): OLIVIA HERDER PATE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: OLIVIA CLAIRE HERDER

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N ELM ST
HIGH POINT NC
27262-4331
US

IV. Provider business mailing address

MEDICAL CENTER BLVD
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-878-6000
  • Fax:
Mailing address:
  • Phone: 336-716-9252
  • Fax: 336-716-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-12554
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-12554
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: