Provider Demographics
NPI:1669505004
Name:GORDON S OLSEN DO PC
Entity Type:Organization
Organization Name:GORDON S OLSEN DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPEDIC SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:S
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:307-789-0096
Mailing Address - Street 1:PO BOX 796
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-0796
Mailing Address - Country:US
Mailing Address - Phone:307-789-0096
Mailing Address - Fax:307-789-0860
Practice Address - Street 1:170 ARROWHEAD DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-9266
Practice Address - Country:US
Practice Address - Phone:307-789-0096
Practice Address - Fax:307-789-0860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY207X00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY00593001OtherBCBS
WY122536700Medicaid
WY122536700Medicaid
WY00593001OtherBCBS