Healthcare Provider Details

I. General information

NPI: 1669505004
Provider Name (Legal Business Name): GORDON S OLSEN DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 03/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 ARROWHEAD DRIVE SUITE 3
EVANSTON WY
82930-9266
US

IV. Provider business mailing address

PO BOX 796
HEBER CITY UT
84032-0796
US

V. Phone/Fax

Practice location:
  • Phone: 307-789-0096
  • Fax: 307-789-0860
Mailing address:
  • Phone: 307-789-0096
  • Fax: 307-789-0860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateWY

VIII. Authorized Official

Name: GORDON S OLSEN
Title or Position: ORTHOPEDIC SURGEON
Credential: D.O.
Phone: 307-789-0096