Healthcare Provider Details

I. General information

NPI: 1952723702
Provider Name (Legal Business Name): HEATHER OLSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER LOVE

II. Dates (important events)

Enumeration Date: 01/14/2014
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 10TH AVE W
MOBRIDGE SD
57601-1146
US

IV. Provider business mailing address

1309 10TH AVE W
MOBRIDGE SD
57601-1146
US

V. Phone/Fax

Practice location:
  • Phone: 605-845-3692
  • Fax: 605-845-8252
Mailing address:
  • Phone: 605-845-3692
  • Fax: 605-845-8252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0904
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: