Healthcare Provider Details

I. General information

NPI: 1184148017
Provider Name (Legal Business Name): ANDREW JACOB OLSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 08/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 NORTHLAND DR
BLOOMINGTON MN
55431-4800
US

IV. Provider business mailing address

325 HILLCREST CIR
CLARKS GROVE MN
56016-9776
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax:
Mailing address:
  • Phone: 507-402-4361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number2979
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: