Provider Demographics
NPI:1710046057
Name:OLSON, RICHARD L (CRNA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:OLSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N3171 STARKEY LAKE RD.
Mailing Address - Street 2:
Mailing Address - City:SHELL LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54871
Mailing Address - Country:US
Mailing Address - Phone:715-468-2057
Mailing Address - Fax:
Practice Address - Street 1:N3171 STARKEY LAKE RD.
Practice Address - Street 2:
Practice Address - City:SHELL LAKE
Practice Address - State:WI
Practice Address - Zip Code:54871
Practice Address - Country:US
Practice Address - Phone:715-468-2057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61226367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43394300Medicaid