Healthcare Provider Details

I. General information

NPI: 1043217664
Provider Name (Legal Business Name): DAVID L OLIVER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2005
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 WASHINGTON WAY
LONGVIEW WA
98632-2952
US

IV. Provider business mailing address

PO BOX 1338
LONGVIEW WA
98632-7785
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-9580
  • Fax: 360-423-6230
Mailing address:
  • Phone: 360-423-0390
  • Fax: 360-577-3865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10001837
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: