Provider Demographics
NPI:1669027025
Name:OLSON, KELLY ERIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ERIN
Last Name:OLSON
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:5720 RALSTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7844
Mailing Address - Country:US
Mailing Address - Phone:805-804-4168
Mailing Address - Fax:805-830-1177
Practice Address - Street 1:2525 ERRINGER RD
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2352
Practice Address - Country:US
Practice Address - Phone:805-527-1404
Practice Address - Fax:805-527-5246
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2023-03-07
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA57237OtherSTATE LICENSE
CAMO5540845OtherDEA