Provider Demographics
NPI:1477516649
Name:OLSEN, RYAN ANTHONY (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:ANTHONY
Last Name:OLSEN
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 1:8100 W 78TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55439-2516
Mailing Address - Country:US
Mailing Address - Phone:952-445-0077
Mailing Address - Fax:
Practice Address - Street 1:8100 W 78TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2516
Practice Address - Country:US
Practice Address - Phone:952-914-8100
Practice Address - Fax:952-914-8501
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN132079OtherUCARE
MN2276559OtherAMERICAS PPO
MNHP48635OtherHEALTHPARTNERS
MNP00113560OtherRAILROAD MEDICARE
MN1032303OtherPREFERRED ONE
MN0112116OtherMEDICA
MN670131100Medicaid
MNO22L40LOtherBLUE CROSS/SHIELD
MN0112116OtherSELECT CARE
MN0112116OtherSELECT CARE
MN970001521Medicare ID - Type UnspecifiedMEDICARE