Provider Demographics
NPI:1417615840
Name:OLSON, EVELINA A
Entity Type:Individual
Prefix:MRS
First Name:EVELINA
Middle Name:A
Last Name:OLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 SWALLOW WAY
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-1648
Mailing Address - Country:US
Mailing Address - Phone:510-915-0158
Mailing Address - Fax:
Practice Address - Street 1:1620 SWALLOW WAY
Practice Address - Street 2:
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-1648
Practice Address - Country:US
Practice Address - Phone:510-915-0158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA08426593207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE0701386OtherDRIVER'S LICENSE