Provider Demographics
NPI:1982407110
Name:OGLE, OLIVIA RAE (PA-C)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RAE
Last Name:OGLE
Suffix:
Gender:
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 1:1940 W ADDISON ST APT 1E
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-6791
Mailing Address - Country:US
Mailing Address - Phone:406-890-8276
Mailing Address - Fax:
Practice Address - Street 1:1940 W ADDISON ST APT 1E
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-6791
Practice Address - Country:US
Practice Address - Phone:406-890-8276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.011205363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant