Provider Demographics
NPI:1720210248
Name:OLSON, DEWAINE ALLEN JR
Entity Type:Individual
Prefix:MR
First Name:DEWAINE
Middle Name:ALLEN
Last Name:OLSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:PETERSON AFB
Mailing Address - State:CO
Mailing Address - Zip Code:80914
Mailing Address - Country:US
Mailing Address - Phone:719-474-3862
Mailing Address - Fax:
Practice Address - Street 1:559 VINCENT ST
Practice Address - Street 2:
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914
Practice Address - Country:US
Practice Address - Phone:719-474-3862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians