Healthcare Provider Details

I. General information

NPI: 1114831609
Provider Name (Legal Business Name): OLVIMAR CAMPOS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1507 AVE PONCE DE LEON APT 205
SAN JUAN PR
00909-2050
US

IV. Provider business mailing address

1509 AVE PONCE DE LEON APT 1445
SAN JUAN PR
00909-2015
US

V. Phone/Fax

Practice location:
  • Phone: 939-475-1414
  • Fax:
Mailing address:
  • Phone: 787-461-4793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3248
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: