Healthcare Provider Details

I. General information

NPI: 1033564760
Provider Name (Legal Business Name): NATHANAEL OLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12639 OLD TESSON RD
SAINT LOUIS MO
63128-2711
US

IV. Provider business mailing address

12639 OLD TESSON RD
SAINT LOUIS MO
63128-2711
US

V. Phone/Fax

Practice location:
  • Phone: 314-849-0311
  • Fax:
Mailing address:
  • Phone: 314-849-0311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2022014038
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number2022014038
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: