Provider Demographics
NPI:1396859112
Name:OLSON, JAMES ROBERT JR (PT ATC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROBERT
Last Name:OLSON
Suffix:JR
Gender:M
Credentials:PT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5985 RICE CREEK PKWY
Mailing Address - Street 2:STE 104
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-5036
Mailing Address - Country:US
Mailing Address - Phone:763-421-9264
Mailing Address - Fax:
Practice Address - Street 1:4625 CHURCHILL STREET
Practice Address - Street 2:MOTIONCARE SHOREVIEW MEDICAL CENTER SUITE 204
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126
Practice Address - Country:US
Practice Address - Phone:651-484-6735
Practice Address - Fax:651-484-5663
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2017-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1579225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02775Medicare ID - Type Unspecified