=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831867555
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIK OLSON NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2021
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 621 MEMORIAL DR STE 502
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-5875
-----------------------------------------------------
Fax | 574-647-5878
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3245 HEALTH DR STE 100
-----------------------------------------------------
City | GRANGER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46530-1380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-6592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 4704351690
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 71014328A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------