Provider Demographics
NPI:1306383633
Name:OLSEN, KELSEY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 654354
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-4354
Mailing Address - Country:US
Mailing Address - Phone:405-364-7900
Mailing Address - Fax:405-366-6214
Practice Address - Street 1:825 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6610
Practice Address - Country:US
Practice Address - Phone:405-364-7900
Practice Address - Fax:405-366-6214
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2723363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1140310OtherNCCPA
OK200697800AMedicaid