1689835977 NPI number — DR. ANDREA GENA OLSON MD

Table of content: DR. ANDREA GENA OLSON MD (NPI 1689835977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689835977 NPI number — DR. ANDREA GENA OLSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLSON
Provider First Name:
ANDREA
Provider Middle Name:
GENA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAETZ
Provider Other First Name:
ANDREA
Provider Other Middle Name:
GENA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689835977
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8170 33RD AVE S
Provider Second Line Business Mailing Address:
MAILSTOP 21110Q
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55425-4516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 JACKSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55101-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-254-4887
Provider Business Practice Location Address Fax Number:
651-254-1603
Provider Enumeration Date:
06/19/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  56117-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 58651 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)