Provider Demographics
NPI:1710393236
Name:OLSON, ROBERT WAYNE JR (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:OLSON
Suffix:JR
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 1:2420 S UNION AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1323
Mailing Address - Country:US
Mailing Address - Phone:360-413-8191
Mailing Address - Fax:253-682-2427
Practice Address - Street 1:3209 S 23RD ST STE 200
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405
Practice Address - Country:US
Practice Address - Phone:253-272-5127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60010416163W00000X
WAAP604744388367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA000357600OtherGROUP MEDICARE #
1730187899OtherGROUP NPI