Healthcare Provider Details

I. General information

NPI: 1205756871
Provider Name (Legal Business Name): LUKE DANIEL OLSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 S 41ST ST
MANITOWOC WI
54220-7316
US

IV. Provider business mailing address

2660 PRAIRIE LAKE RD
TOMAHAWK WI
54487-8881
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-4780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: