Healthcare Provider Details

I. General information

NPI: 1689622979
Provider Name (Legal Business Name): THOMAS L OLMSTED CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COUNTY ROAD B
SHAWANO WI
54166-7072
US

IV. Provider business mailing address

PO BOX 8003
APPLETON WI
54912-8003
US

V. Phone/Fax

Practice location:
  • Phone: 715-524-2161
  • Fax:
Mailing address:
  • Phone: 920-996-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number67387-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: