Healthcare Provider Details

I. General information

NPI: 1891419370
Provider Name (Legal Business Name): JONATHAN TREVOR OSBORNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 GREENE ST
COLUMBIA SC
29208-4001
US

IV. Provider business mailing address

1601 GREEN STREET
COLUMBIA SC
29208-0001
US

V. Phone/Fax

Practice location:
  • Phone: 803-777-7412
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number27665
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: