Healthcare Provider Details

I. General information

NPI: 1881822203
Provider Name (Legal Business Name): SAMUEL R OLSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 07/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1185 TOWN CENTRE DR STE 100
EAGAN MN
55123-1188
US

IV. Provider business mailing address

710 COMMERCE DR STE 200
WOODBURY MN
55125-4925
US

V. Phone/Fax

Practice location:
  • Phone: 651-968-5230
  • Fax: 651-994-3982
Mailing address:
  • Phone: 651-968-5042
  • Fax: 651-968-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number8358
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: