Provider Demographics
NPI:1407154354
Name:OLSEN, AMANDA S (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:S
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:S
Other - Last Name:WOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2200 DICKINSON RD UNIT 17B
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-4070
Mailing Address - Country:US
Mailing Address - Phone:920-965-1234
Mailing Address - Fax:920-965-1232
Practice Address - Street 1:2200 DICKINSON RD UNIT 17B
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-4070
Practice Address - Country:US
Practice Address - Phone:920-965-1234
Practice Address - Fax:920-965-1232
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4138363A00000X
WI3281-23363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3281-23OtherWISCONSIN PA LICENSE
WI100037410Medicaid
MAPA4138OtherLICENSE NUMBER