Healthcare Provider Details

I. General information

NPI: 1023720612
Provider Name (Legal Business Name): EMMANUEL OTSIN CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

IV. Provider business mailing address

249 WARRIOR RD
DREXEL HILL PA
19026-5026
US

V. Phone/Fax

Practice location:
  • Phone: 270-406-0681
  • Fax:
Mailing address:
  • Phone: 270-406-0681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberSP026679
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: