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General NPI Number Information
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NPI Number | 1477062693
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Entity Type | Individual
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Provider Name | INGRID M OLSSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/20/2017
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Last Update Date | 12/16/2021
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Provider Practice Location Address
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Address Line | 255 E BONITA AVE BLDG 9
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City | POMONA
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State | CA
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Zip | 91767-1923
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Country | US
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Telephone | 909-301-8897
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Fax |
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Provider Business Mailing Address
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Address Line | 11100 4TH ST APT G306
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-0909
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Country | US
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Telephone | 603-718-4179
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 1516
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License Number State | NH
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