Provider Demographics
NPI:1346961158
Name:PATE, OLIVIA HERDER (PA-C)
Entity type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:HERDER
Last Name:PATE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:CLAIRE
Other - Last Name:HERDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-9252
Mailing Address - Fax:336-716-0030
Practice Address - Street 1:601 N ELM ST
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4331
Practice Address - Country:US
Practice Address - Phone:336-878-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12554363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1346961158Medicaid