NPIMap

Individual provider Active NPI

Olga Sambu

  • Physician Assistant
  • SLC, UT
National Provider Identifier
1811464076
Registry record updated Jan 9, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
11932196-1206 Issued in UT
Practice address
375 S Chipeta Way
SLC, UT 84108-1260
Phone
(801) 581-7766
NPI assigned
Oct 25, 2018
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 9, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Student in an Organized Health Care Education/Training Program 390200000X
Physician Assistant 363A00000X 11932196-1206 UT Primary

Addresses

Primary practice location

375 S Chipeta Way
SLC, UT 84108-1260

Mailing address

1055 N 500 W, Att: Credentialing
Provo, UT 84604
Phone (801) 354-8225

Other practice location 1

1055 N 500 W Ste 111
Provo, UT 84604-3305
Phone (801) 374-8999

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address medreview@reverehealth.com Revere Health PC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in UT
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20210115001807 UT Practitioner - Physician Assistant 3375956147 Reassigns benefits to 1 organization

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
11932196-1206UTMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Revere Health PC CurrentSince Jan 4, 2021 Accepting new patients
Revere Health PC CurrentSince Jan 4, 2021 Accepting new patients
Karen Stolman MD PC Past Accepting new patients
DMB Medical PLLC Past Accepting new patients

Locations

1055 N 500 W
Ste 111
Provo, UT 84604
Phone (801) 374-8999

1055 N 500 W
Provo, UT 84604
Phone (801) 429-8000

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1540425600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1610150400000",
    "number": "1811464076",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1055 N 500 W, ATT: CREDENTIALING",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "84604",
            "telephone_number": "801-354-8225",
            "fax_number": "801-418-0941"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "375 S CHIPETA WAY",
            "city": "SLC",
            "state": "UT",
            "postal_code": "841081260",
            "telephone_number": "801-581-7766"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1055 N 500 W Ste 111",
            "address_purpose": "LOCATION",
            "city": "Provo",
            "state": "UT",
            "postal_code": "846043305",
            "country_code": "US",
            "telephone_number": "801-374-8999",
            "fax_number": "801-429-8063",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "SAMBU",
        "first_name": "OLGA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-10-25",
        "last_updated": "2021-01-09",
        "certification_date": "2021-01-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "UT",
            "license": "11932196-1206",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "medreview@reverehealth.com",
            "affiliation": "Y",
            "affiliationName": "Revere Health PC",
            "address_1": "1055 N 500 W Ste 111",
            "city": "Provo",
            "state": "UT",
            "country_code": "US",
            "postal_code": "846043305",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in SLC, UT

Sources for this page

Verify at the official NPI Registry.