Basic Information
| Provider Information | |||||||||
| NPI: | 1790737054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSON | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3420 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549018144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204262211 | ||||||||
| FaxNumber: | 9204262231 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S OAKWOOD RD | ||||||||
| Address2: | |||||||||
| City: | OSHKOSH | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549047944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202232000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 57971030 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 43278100 | 05 | WI | MEDICAID |