Provider Demographics
NPI:1174092498
Name:MURATIDES, OLIVIA LEIGH (PA)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:LEIGH
Last Name:MURATIDES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2923 W KNIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-1621
Mailing Address - Country:US
Mailing Address - Phone:813-817-2466
Mailing Address - Fax:
Practice Address - Street 1:1607 DR MARTIN LUTHER KING JR ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704-4203
Practice Address - Country:US
Practice Address - Phone:727-329-8833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2019-02-01
Deactivation Date:2018-11-18
Deactivation Code:
Reactivation Date:2019-01-30
Provider Licenses
StateLicense IDTaxonomies
FL9111605363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant