Provider Demographics
NPI:1124493259
Name:OLBETER, JOHN WILIAM (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:WILIAM
Last Name:OLBETER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-5702
Mailing Address - Country:US
Mailing Address - Phone:516-695-5994
Mailing Address - Fax:
Practice Address - Street 1:11 1ST AVE
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-5702
Practice Address - Country:US
Practice Address - Phone:516-695-5994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019359363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant