Provider Demographics
NPI: | 1710633029 |
---|---|
Name: | KHOURY, OLIVIA MARIE (PA-C) |
Entity type: | Individual |
Prefix: | MRS |
First Name: | OLIVIA |
Middle Name: | MARIE |
Last Name: | KHOURY |
Suffix: | |
Gender: | |
Credentials: | PA-C |
Other - Prefix: | MS |
Other - First Name: | OLIVIA |
Other - Middle Name: | MARIE |
Other - Last Name: | GHANNAM |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | OLIVIA MARIE GHANNAM |
Mailing Address - Street 1: | 13440 UNIVERSITY BLVD STE 100 |
Mailing Address - Street 2: | |
Mailing Address - City: | SUGAR LAND |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 77479-4907 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 832-500-8135 |
Mailing Address - Fax: | 833-521-2186 |
Practice Address - Street 1: | 13440 UNIVERSITY BLVD STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | SUGAR LAND |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77479-4907 |
Practice Address - Country: | US |
Practice Address - Phone: | 832-500-8135 |
Practice Address - Fax: | 833-521-2186 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2022-02-24 |
Last Update Date: | 2025-04-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 5601010964 | 363A00000X |
TX | PA17711 | 363AS0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |