Provider Demographics
NPI:1265036925
Name:SHENOUDA, OSAMA (PTA)
Entity Type:Individual
Prefix:
First Name:OSAMA
Middle Name:
Last Name:SHENOUDA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:554 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-1338
Mailing Address - Country:US
Mailing Address - Phone:973-483-2277
Mailing Address - Fax:973-483-4577
Practice Address - Street 1:554 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1338
Practice Address - Country:US
Practice Address - Phone:973-483-2277
Practice Address - Fax:973-483-4577
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00380300225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant