Provider Demographics
NPI:1093164006
Name:OLK, MARI
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:
Last Name:OLK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 E 1ST ST STE 203
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2297
Mailing Address - Country:US
Mailing Address - Phone:218-249-5555
Mailing Address - Fax:
Practice Address - Street 1:1000 E 1ST ST STE 203
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2297
Practice Address - Country:US
Practice Address - Phone:218-249-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMW4569490363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORMW4569490OtherMEDICAL LICENSE