Provider Demographics
NPI:1902813645
Name:OLSON, KEVIN K (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:OLSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 277279
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7279
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-527-5510
Practice Address - Street 1:3200 SW 60TH CT
Practice Address - Street 2:SUITE 104
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4000
Practice Address - Country:US
Practice Address - Phone:305-669-6448
Practice Address - Fax:305-663-8485
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9100945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290659700Medicaid