Healthcare Provider Details

I. General information

NPI: 1275366346
Provider Name (Legal Business Name): OWEN KONZELMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 CHAPEL AVE W
CHERRY HILL NJ
08002-2048
US

IV. Provider business mailing address

721 WINCHESTER RD
BROOMALL PA
19008-3432
US

V. Phone/Fax

Practice location:
  • Phone: 856-488-6500
  • Fax:
Mailing address:
  • Phone: 610-545-3722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00882200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: