Provider Demographics
NPI:1952723702
Name:OLSON, HEATHER (PA-C)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:LOVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1309 10TH AVE W
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-1146
Mailing Address - Country:US
Mailing Address - Phone:605-845-3692
Mailing Address - Fax:605-845-8252
Practice Address - Street 1:1309 10TH AVE W
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601-1146
Practice Address - Country:US
Practice Address - Phone:605-845-3692
Practice Address - Fax:605-845-8252
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S108186OtherPTAN
SD1952723702Medicaid