Healthcare Provider Details

I. General information

NPI: 1063043982
Provider Name (Legal Business Name): JOSE DANIEL OLIVERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2020
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 SAND POINT WAY NE STE 100
SEATTLE WA
98105-3901
US

IV. Provider business mailing address

13021 27TH AVE NE
SEATTLE WA
98125-4313
US

V. Phone/Fax

Practice location:
  • Phone: 206-987-8450
  • Fax:
Mailing address:
  • Phone: 423-309-4962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP61034008
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: