Provider Demographics
NPI:1548087422
Name:OLSON, MIA
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:OLSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:HENDRIX
Other - Middle Name:
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 449
Mailing Address - Street 2:
Mailing Address - City:TESUQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87574-0449
Mailing Address - Country:US
Mailing Address - Phone:505-983-6158
Mailing Address - Fax:
Practice Address - Street 1:1160 PARKWAY DR STE AB
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-7322
Practice Address - Country:US
Practice Address - Phone:505-983-6158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker