Provider Demographics
NPI:1306522776
Name:CUSUMANO, OLIVIA JANE (PA-C)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:JANE
Last Name:CUSUMANO
Suffix:
Gender:F
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 1:3413 WOODS EDGE
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-5901
Mailing Address - Country:US
Mailing Address - Phone:517-349-3303
Mailing Address - Fax:
Practice Address - Street 1:3413 WOODS EDGE
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-5901
Practice Address - Country:US
Practice Address - Phone:517-349-3303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011837363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant