Basic Information
| Provider Information | |||||||||
| NPI: | 1598358285 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 280 | ||||||||
| Address2: | |||||||||
| City: | PRESTONSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 416530280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063498100 | ||||||||
| FaxNumber: | 6063498150 | ||||||||
| Practice Location | |||||||||
| Address1: | 842 E MOUNTAIN PKWY | ||||||||
| Address2: | |||||||||
| City: | SALYERSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 414658378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063498100 | ||||||||
| FaxNumber: | 6063498150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2021 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | TC998 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA2727 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100734060 | 05 | KY | MEDICAID |