Provider Demographics
NPI:1124132089
Name:OLIVER, PAUL (PA)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:OLIVER
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 1:330 ORCHARD ST.
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511
Mailing Address - Country:US
Mailing Address - Phone:203-789-3152
Mailing Address - Fax:203-867-5457
Practice Address - Street 1:330 ORCHARD ST.
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-789-3152
Practice Address - Fax:203-867-5457
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1264363AM0700X
CT001264363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q44614Medicare UPIN