Provider Demographics
NPI:1033776562
Name:OLSON, RAY BROCK (PA)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:BROCK
Last Name:OLSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 N 400 E
Mailing Address - Street 2:STE 301
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1892
Mailing Address - Country:US
Mailing Address - Phone:435-753-7880
Mailing Address - Fax:435-359-4507
Practice Address - Street 1:2245 N 400 E
Practice Address - Street 2:STE 301
Practice Address - City:NORTH LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1892
Practice Address - Country:US
Practice Address - Phone:435-753-7880
Practice Address - Fax:435-359-4507
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2022-06-24
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1548303795Medicaid