Provider Demographics
NPI:1275703928
Name:OLSON, ROGER A
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:A
Last Name:OLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 N 400 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1749
Mailing Address - Country:US
Mailing Address - Phone:435-713-9700
Mailing Address - Fax:435-753-8005
Practice Address - Street 1:2380 N 400 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-1749
Practice Address - Country:US
Practice Address - Phone:435-713-9700
Practice Address - Fax:435-753-8005
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT114477-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT460054Medicare Oscar/Certification