Provider Demographics
NPI:1407856917
Name:OLSEN, MARILYN E (PA)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:E
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 STRAITS TPKE
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-2843
Mailing Address - Country:US
Mailing Address - Phone:203-758-1800
Mailing Address - Fax:203-758-1804
Practice Address - Street 1:850 STRAITS TPKE
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-2843
Practice Address - Country:US
Practice Address - Phone:203-758-1800
Practice Address - Fax:203-758-1804
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000797363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S68303Medicare UPIN