Provider Demographics
NPI:1326233610
Name:OLSEN, INGRID ADAMS (PT, PA-C)
Entity Type:Individual
Prefix:MS
First Name:INGRID
Middle Name:ADAMS
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PT, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 N FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-4208
Mailing Address - Country:US
Mailing Address - Phone:143-561-3220
Mailing Address - Fax:143-561-3220
Practice Address - Street 1:377 N FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-4208
Practice Address - Country:US
Practice Address - Phone:143-561-3220
Practice Address - Fax:143-561-3220
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6161225100000X
UT295070-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTDF8294OtherRAILROAD MEDICARE
UT000062016Medicare PIN