Provider Demographics
NPI:1104847847
Name:OLSON, PERRY J (PA-C)
Entity Type:Individual
Prefix:
First Name:PERRY
Middle Name:J
Last Name:OLSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23161 BRITNER CT
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4707
Mailing Address - Country:US
Mailing Address - Phone:248-988-8227
Mailing Address - Fax:
Practice Address - Street 1:20400 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3242
Practice Address - Country:US
Practice Address - Phone:313-271-0500
Practice Address - Fax:313-271-9319
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI364544473363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00219893OtherRAILROAD MEDICARE
MIN85980002Medicare PIN
MIP00219893OtherRAILROAD MEDICARE