Provider Demographics
NPI:1770990848
Name:OLISE, PATRICK (PA)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:OLISE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844088
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4088
Mailing Address - Country:US
Mailing Address - Phone:505-609-2258
Mailing Address - Fax:505-609-2259
Practice Address - Street 1:55 WHITCHER ST NE STE 160
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1160
Practice Address - Country:US
Practice Address - Phone:770-422-1372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2016-0024363A00000X
GA7242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant