Provider Demographics
NPI:1083152680
Name:OLSON, LYNDSEY (PA)
Entity Type:Individual
Prefix:
First Name:LYNDSEY
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LYNDSEY
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4055 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2149
Practice Address - Country:US
Practice Address - Phone:616-252-4410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008096363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2051Medicare PIN