Basic Information
| Provider Information | |||||||||
| NPI: | 1528441722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLLISO | ||||||||
| FirstName: | JEREMIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5005 N PIEDRAS ST | ||||||||
| Address2: | WBAMC | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155694890 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5005 N PIEDRAS ST | ||||||||
| Address2: | WBAMC | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799205002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155694890 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2015 | ||||||||
| LastUpdateDate: | 07/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1127053 | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.