Provider Demographics
NPI:1184148017
Name:OLSON, ANDREW JACOB (ATC)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:JACOB
Last Name:OLSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 HILLCREST CIR
Mailing Address - Street 2:
Mailing Address - City:CLARKS GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:56016-9776
Mailing Address - Country:US
Mailing Address - Phone:507-402-4361
Mailing Address - Fax:
Practice Address - Street 1:8100 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-4800
Practice Address - Country:US
Practice Address - Phone:952-831-8742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2979204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine