Provider Demographics
NPI:1578185757
Name:OLARTE, KATRYNA FEDORA
Entity type:Individual
Prefix:
First Name:KATRYNA
Middle Name:FEDORA
Last Name:OLARTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 W CANOGA PL APT 1
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-2751
Mailing Address - Country:US
Mailing Address - Phone:714-851-6120
Mailing Address - Fax:
Practice Address - Street 1:23181 VERDUGO DR STE 103A
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1313
Practice Address - Country:US
Practice Address - Phone:949-366-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA59397363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program