=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295738789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN KAY OLSON CNP/PAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2005
-----------------------------------------------------
Last Update Date | 11/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 KANSAS AVE SE
-----------------------------------------------------
City | HURON
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57350-2522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-352-8767
-----------------------------------------------------
Fax | 605-352-8784
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1411
-----------------------------------------------------
City | HURON
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57350-1411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-352-8767
-----------------------------------------------------
Fax | 605-352-8784
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | CP000049
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0625
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------