Provider Demographics
NPI:1093259921
Name:OLSON, LAURA (DOM)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22187
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-2187
Mailing Address - Country:US
Mailing Address - Phone:505-983-1234
Mailing Address - Fax:844-450-2837
Practice Address - Street 1:511 W SAN MATEO RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4027
Practice Address - Country:US
Practice Address - Phone:505-983-1234
Practice Address - Fax:844-450-2837
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM465171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist