Provider Demographics
NPI:1245312453
Name:OLSON, HOLLI JOY (PA-C)
Entity type:Individual
Prefix:
First Name:HOLLI
Middle Name:JOY
Last Name:OLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MONTEVIDEO VA CLINIC
Mailing Address - Street 2:1025 N 13TH STREET
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265
Mailing Address - Country:US
Mailing Address - Phone:320-269-2222
Mailing Address - Fax:
Practice Address - Street 1:MONTEVIDEO VA CLINIC
Practice Address - Street 2:1025 N 13TH STREET
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265-1653
Practice Address - Country:US
Practice Address - Phone:320-269-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3125363AS0400X
MN12943363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ907678Medicaid
AZ8HD005Medicare ID - Type UnspecifiedPART B
AZ030078Medicare Oscar/Certification
AZ907678Medicaid