Provider Demographics
NPI:1609652494
Name:BASILE, OLIVIA RAE (PA-C)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RAE
Last Name:BASILE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:RAE
Other - Last Name:WEASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-1267
Mailing Address - Country:US
Mailing Address - Phone:336-783-8911
Mailing Address - Fax:336-786-3752
Practice Address - Street 1:119 WELCH RD STE A
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-5274
Practice Address - Country:US
Practice Address - Phone:336-719-7200
Practice Address - Fax:336-786-3737
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant