Provider Demographics
NPI:1447826391
Name:OLSEN, DAVID C
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:OLSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4998 S OREGON TRAIL WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-7139
Mailing Address - Country:US
Mailing Address - Phone:507-649-0755
Mailing Address - Fax:
Practice Address - Street 1:4998 S OREGON TRAIL WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-7139
Practice Address - Country:US
Practice Address - Phone:507-649-0755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-01
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC252654163W00000X
ID71642367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse