Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 2979 | MN |
NPI | 1184148017 |
---|---|
Provider Name | Andrew Jacob Olson |
First Address | Clarks Grove, MN 56016-9776 |
Second Address | Bloomington, MN 55431-4800 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/08/2017 |
Last Update Date | 02/08/2017 |