Provider Demographics
NPI:1629529623
Name:OLSON, RYAN (PT)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 720908
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-4708
Mailing Address - Country:US
Mailing Address - Phone:405-809-8713
Mailing Address - Fax:
Practice Address - Street 1:1266 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-1918
Practice Address - Country:US
Practice Address - Phone:608-318-1357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022391225100000X
WI13624 - 24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070022391OtherIL PT LICENSE
WI13624 - 24OtherWI PT LICENSE