Provider Demographics
NPI:1104535772
Name:GOLDBERG, OLIVIA (PAC)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W MAIN ST STE 267
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2537
Mailing Address - Country:US
Mailing Address - Phone:609-921-9001
Mailing Address - Fax:
Practice Address - Street 1:901 W MAIN ST STE 267
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2537
Practice Address - Country:US
Practice Address - Phone:609-921-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064308363A00000X
NJ25MP00760400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant