Provider Demographics
NPI:1396753497
Name:OLSON, KIRK MYKEL (PA)
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:MYKEL
Last Name:OLSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 RAYOVAC DR.
Mailing Address - Street 2:#103
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2479
Mailing Address - Country:US
Mailing Address - Phone:608-238-5826
Mailing Address - Fax:608-238-1221
Practice Address - Street 1:700 RAYOVAC DR.
Practice Address - Street 2:#103
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2479
Practice Address - Country:US
Practice Address - Phone:608-238-5826
Practice Address - Fax:608-238-1221
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1045705363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1396753497Medicaid