Healthcare Provider Details

I. General information

NPI: 1417615840
Provider Name (Legal Business Name): MRS. EVELINA A. OLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 SWALLOW WAY
HERCULES CA
94547-1648
US

IV. Provider business mailing address

1620 SWALLOW WAY
HERCULES CA
94547-1648
US

V. Phone/Fax

Practice location:
  • Phone: 510-915-0158
  • Fax:
Mailing address:
  • Phone: 510-915-0158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number08426593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: