Healthcare Provider Details

I. General information

NPI: 1710751615
Provider Name (Legal Business Name): CAROLYN OLIVEIRA NASCIMENTO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

89 LOGAN LN
LYNCHBURG VA
24502-7321
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-9999
  • Fax:
Mailing address:
  • Phone: 617-365-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009620
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: