Healthcare Provider Details

I. General information

NPI: 1891278818
Provider Name (Legal Business Name): ADDASON ROMANA OLVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 UNIVERSITY BLVD
TYLER TX
75799-6600
US

IV. Provider business mailing address

906 SWINGING BRIDGE RD
LONGVIEW TX
75604-5717
US

V. Phone/Fax

Practice location:
  • Phone: 903-565-5777
  • Fax:
Mailing address:
  • Phone: 903-746-9823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: