Provider Demographics
NPI:1093782856
Name:OSTA, ISMAEL S (PA C)
Entity Type:Individual
Prefix:MR
First Name:ISMAEL
Middle Name:S
Last Name:OSTA
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3226 HAMPTON AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520
Mailing Address - Country:US
Mailing Address - Phone:912-265-1212
Mailing Address - Fax:912-265-2859
Practice Address - Street 1:3226 HAMPTON AVE
Practice Address - Street 2:SUITE G
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4225
Practice Address - Country:US
Practice Address - Phone:912-265-1212
Practice Address - Fax:912-265-2859
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA003966363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA021787368CMedicaid
P83613Medicare UPIN
GA97WCGVVMedicare ID - Type Unspecified