Provider Demographics
NPI:1528406873
Name:OLESON, NICHOLAS EDWIN
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EDWIN
Last Name:OLESON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 CHERRY BARK LOOP
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27527-9522
Mailing Address - Country:US
Mailing Address - Phone:412-719-9175
Mailing Address - Fax:
Practice Address - Street 1:3100 DURALEIGH RD STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8105
Practice Address - Country:US
Practice Address - Phone:919-788-8797
Practice Address - Fax:919-788-8798
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07939363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant