Provider Demographics
NPI:1942743950
Name:OLSON, THOMAS ANTHONY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ANTHONY
Last Name:OLSON
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1591 106TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-6308
Mailing Address - Country:US
Mailing Address - Phone:612-968-5133
Mailing Address - Fax:
Practice Address - Street 1:2115 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1096
Practice Address - Country:US
Practice Address - Phone:612-968-5133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000028350OtherNATA BOARD OF CERTIFICATION
MN3105OtherMINNESOTA STATE LICENSURE