Provider Demographics
NPI:1083677876
Name:OLSON, ERIC (PA)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2588 S FOREST MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-5016
Mailing Address - Country:US
Mailing Address - Phone:928-528-7523
Mailing Address - Fax:928-532-1969
Practice Address - Street 1:2450 E SHOW LOW LAKE RD STE 1
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7953
Practice Address - Country:US
Practice Address - Phone:928-532-5577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2263363A00000X
NM2001-PA28174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ578385Medicaid
NMS6576Medicaid
NMS6576Medicaid