Healthcare Provider Details

I. General information

NPI: 1609464122
Provider Name (Legal Business Name): GABRIEL LAMONT OLLISON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2021
Last Update Date: 01/10/2021
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 SALISBURY ST
WADESBORO NC
28170-2155
US

IV. Provider business mailing address

611 WILDERNESS TRAIL DR
CHARLOTTE NC
28214-5006
US

V. Phone/Fax

Practice location:
  • Phone: 704-694-6700
  • Fax:
Mailing address:
  • Phone: 704-968-0766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-10900
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: