Healthcare Provider Details

I. General information

NPI: 1386953172
Provider Name (Legal Business Name): LEAH CAMILLE ANDERSON OLSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEAH CAMILLE ANDERSON

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 E HURON ST STE 16-738
CHICAGO IL
60611-3055
US

IV. Provider business mailing address

251 E HURON ST STE 16-738
CHICAGO IL
60611-3055
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-5924
  • Fax: 312-926-6134
Mailing address:
  • Phone: 312-926-5924
  • Fax: 312-926-6134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085004253
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004253
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: