Provider Demographics
NPI:1427028067
Name:OLLIVIER, JOSEPH EMILIAN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:EMILIAN
Last Name:OLLIVIER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 SUNBURST ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3151
Mailing Address - Country:US
Mailing Address - Phone:208-320-7250
Mailing Address - Fax:
Practice Address - Street 1:500 W FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4501
Practice Address - Country:US
Practice Address - Phone:208-422-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-351363AM0700X
IDPA351363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID085960OtherBLUE SHIELD
IDPA351OtherSTATE LICENSE
ID000010032407OtherBLUE SHIELD OF IDAHO
ID806032100Medicaid
IDPAIM4OtherBLUE CROSS OF IDAHO
ID806032101Medicaid
ID820227163G040OtherTRICARE
IDPA351OtherBLUE CROSS OF IDAHO
ID000010032406OtherBLUE SHIELD OF IDAHO
ID806032100Medicaid
ID806032101Medicaid