Provider Demographics
NPI:1457935330
Name:OLSTAD, GARETH MAGNUS (PA-C)
Entity type:Individual
Prefix:
First Name:GARETH
Middle Name:MAGNUS
Last Name:OLSTAD
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 1:3210 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-7362
Mailing Address - Country:US
Mailing Address - Phone:509-370-8151
Mailing Address - Fax:
Practice Address - Street 1:26 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1309
Practice Address - Country:US
Practice Address - Phone:509-747-5615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61156842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant