Provider Demographics
NPI:1871553024
Name:OLSEN, KEVIN R (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:OLSEN
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:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ME
Mailing Address - Zip Code:04457-0099
Mailing Address - Country:US
Mailing Address - Phone:207-794-6700
Mailing Address - Fax:207-794-6777
Practice Address - Street 1:175 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-0000
Practice Address - Country:US
Practice Address - Phone:207-794-6700
Practice Address - Fax:207-794-2572
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME100273OtherANTHEM
ME201856OtherNGS
ME330920099Medicaid
ME100273OtherANTHEM