Provider Demographics
NPI:1003803339
Name:OLSON, JEREMI THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMI
Middle Name:THOMAS
Last Name:OLSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:DEAN ST. MARY'S OUTPATIENT CENTER
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-260-2900
Mailing Address - Fax:608-260-7975
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:DEAN ST. MARY'S OUTPATIENT CENTER
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-260-2900
Practice Address - Fax:608-260-7975
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1489-023363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI60570OtherDEAN HEALTH INSURANCE
WI41966100Medicaid
P79011Medicare UPIN
WI41966100Medicaid
WI010A74150Medicare PIN