Basic Information
| Provider Information | |||||||||
| NPI: | 1528202280 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLIVEROS | ||||||||
| FirstName: | MYRA | ||||||||
| MiddleName: | CALONGCAGONG | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18075 TOMPKINS CT | ||||||||
| Address2: | |||||||||
| City: | DUMFRIES | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220262477 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 DAIRY LN | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224052663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403719414 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2009 | ||||||||
| LastUpdateDate: | 04/25/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 2305205351 | VA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.