Healthcare Provider Details

I. General information

NPI: 1124372149
Provider Name (Legal Business Name): GARY OSIRUS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2012
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3146 N JOG RD 12211
WEST PALM BEACH FL
33411-7416
US

IV. Provider business mailing address

3146 N JOG RD 12211
WEST PALM BEACH FL
33411-7416
US

V. Phone/Fax

Practice location:
  • Phone: 772-480-8871
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40QB00283900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: