Healthcare Provider Details

I. General information

NPI: 1720090061
Provider Name (Legal Business Name): JOSE EDUARDO OSORIO-LOPEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6150 N US HIGHWAY 41
APOLLO BEACH FL
33572-1806
US

IV. Provider business mailing address

2370 CORPORATE CIR STE 300
HENDERSON NV
89074-7760
US

V. Phone/Fax

Practice location:
  • Phone: 813-641-0007
  • Fax: 813-641-0009
Mailing address:
  • Phone: 702-910-3950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101902
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: