Provider Demographics
NPI:1295379527
Name:OLSON, MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 99213
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0213
Mailing Address - Country:US
Mailing Address - Phone:682-885-4446
Mailing Address - Fax:817-810-1396
Practice Address - Street 1:1401 W PULASKI ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2717
Practice Address - Country:US
Practice Address - Phone:682-885-8012
Practice Address - Fax:682-885-8014
Is Sole Proprietor?:No
Enumeration Date:2019-10-30
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant