=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922876531
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZOBAKU ACHOLONU PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2023
-----------------------------------------------------
Last Update Date | 09/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 MONUMENT RD STE 301
-----------------------------------------------------
City | BALA CYNWYD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19004-1716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-666-7340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 N 41ST ST APT 4
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19104-5763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-813-6281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | MA065019
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------