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General NPI Number Information
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NPI Number | 1649232877
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Entity Type | Individual
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Provider Name | KENNETH MICHAEL OLSON P.A. - C
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Gender | Male
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Dates
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Enumeration Date | 04/04/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 915 N GRAND BLVD 11F/JC ST. LOUIS VA
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City | SAINT LOUIS
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State | MO
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Zip | 63106-1621
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Country | US
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Telephone | 314-652-4100
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Fax |
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Provider Business Mailing Address
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Address Line | 840 CASTLEAIRE PKWY
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City | SAINT LOUIS
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State | MO
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Zip | 63129-2049
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Country | US
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Telephone | 314-892-6195
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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