Provider Demographics
NPI:1033419239
Name:OLSON, EVAN ROBERT (DPT)
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:ROBERT
Last Name:OLSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-439-1234
Mailing Address - Fax:
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4589225100000X
MN11064225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8895729OtherMEDICARE