Provider Demographics
NPI:1851078711
Name:OLSON, MARK JOHN
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JOHN
Last Name:OLSON
Suffix:
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:PO BOX 26
Mailing Address - Street 2:
Mailing Address - City:SANDSTONE
Mailing Address - State:MN
Mailing Address - Zip Code:55072-0026
Mailing Address - Country:US
Mailing Address - Phone:320-245-5355
Mailing Address - Fax:320-216-7638
Practice Address - Street 1:606 HIGHWAY 123 W
Practice Address - Street 2:
Practice Address - City:SANDSTONE
Practice Address - State:MN
Practice Address - Zip Code:55072-5060
Practice Address - Country:US
Practice Address - Phone:320-245-5355
Practice Address - Fax:320-216-7638
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA301047099604172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver