Provider Demographics
NPI:1104532555
Name:OLSON, TRACY (PTA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11930 PORTAGE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-3124
Mailing Address - Country:US
Mailing Address - Phone:907-441-7138
Mailing Address - Fax:
Practice Address - Street 1:10950 OMALLEY CENTRE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-3000
Practice Address - Country:US
Practice Address - Phone:907-341-5240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK202355225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant