1750576617 NPI number — MR. OSWALD JUNIOR ALPHONSE PA-C

Table of content: MR. OSWALD JUNIOR ALPHONSE PA-C (NPI 1750576617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750576617 NPI number — MR. OSWALD JUNIOR ALPHONSE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALPHONSE
Provider First Name:
OSWALD
Provider Middle Name:
JUNIOR
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750576617
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 417
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STUART
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34995-0417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-223-2832
Provider Business Mailing Address Fax Number:
772-223-2847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 S KANNER HWY STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994-4801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-223-4978
Provider Business Practice Location Address Fax Number:
772-223-2847
Provider Enumeration Date:
09/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9104344 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y02YX . This is a "FL BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 293039100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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