Healthcare Provider Details

I. General information

NPI: 1992428882
Provider Name (Legal Business Name): BENJAMIN A OLSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-4800
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011216
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: