Healthcare Provider Details

I. General information

NPI: 1891936779
Provider Name (Legal Business Name): OLGA AKSELROD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SUMMIT AVE
MONTVALE NJ
07645
US

IV. Provider business mailing address

225 SUMMIT AVE
MONTVALE NJ
07645-1523
US

V. Phone/Fax

Practice location:
  • Phone: 201-775-7512
  • Fax: 212-452-3323
Mailing address:
  • Phone: 201-775-7512
  • Fax: 212-452-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00215100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP 00215100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number013140-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: