Provider Demographics
NPI:1326340225
Name:OLSON, JOHN DENTON (PA- C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DENTON
Last Name:OLSON
Suffix:
Gender:M
Credentials:PA- C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31675 CALLE BARCALDO
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-3611
Mailing Address - Country:US
Mailing Address - Phone:951-302-0641
Mailing Address - Fax:951-302-0642
Practice Address - Street 1:31675 CALLE BARCALDO
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-3611
Practice Address - Country:US
Practice Address - Phone:951-302-0641
Practice Address - Fax:951-302-0642
Is Sole Proprietor?:No
Enumeration Date:2010-11-28
Last Update Date:2010-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant