Provider Demographics
NPI:1164446027
Name:OLSEN, CLINTON (PA)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:
Last Name:OLSEN
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 1:16 MOREY AVE
Mailing Address - Street 2:
Mailing Address - City:DANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14437-1146
Mailing Address - Country:US
Mailing Address - Phone:585-335-5329
Mailing Address - Fax:
Practice Address - Street 1:1160 CHILI AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-3035
Practice Address - Country:US
Practice Address - Phone:585-426-4990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11208363A00000X
NY011208363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical