Healthcare Provider Details

I. General information

NPI: 1649232877
Provider Name (Legal Business Name): KENNETH MICHAEL OLSON P.A. - C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD 11F/JC ST. LOUIS VA
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

840 CASTLEAIRE PKWY
SAINT LOUIS MO
63129-2049
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 314-892-6195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: