Provider Demographics
NPI:1386045367
Name:OLM, MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:OLM
Suffix:
Gender:M
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 1:320 POMFRET ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:608-928-6541
Mailing Address - Fax:860-963-6032
Practice Address - Street 1:35 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1939
Practice Address - Country:US
Practice Address - Phone:860-963-3883
Practice Address - Fax:860-963-6032
Is Sole Proprietor?:No
Enumeration Date:2014-09-10
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1045363A00000X
CT4049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant