Provider Demographics
NPI:1215278783
Name:OLTON, RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:OLTON
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 1:12128 STREAMBED DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-9336
Mailing Address - Country:US
Mailing Address - Phone:813-391-6682
Mailing Address - Fax:
Practice Address - Street 1:2523 DORA AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4977
Practice Address - Country:US
Practice Address - Phone:352-508-5176
Practice Address - Fax:352-508-5179
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106951363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008420100Medicaid