Provider Demographics
NPI:1053146571
Name:VANDERSLICE, OLIVIA KATHRYN (PA-C)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:KATHRYN
Last Name:VANDERSLICE
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 1:210 JENKINS RANCH RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-9502
Mailing Address - Country:US
Mailing Address - Phone:214-868-9895
Mailing Address - Fax:
Practice Address - Street 1:2775 SW 17TH PL
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1254
Practice Address - Country:US
Practice Address - Phone:541-504-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR222667363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant