Provider Demographics
NPI:1477051514
Name:KWAIDAH, OTHELLO SAYE (CRNP)
Entity Type:Individual
Prefix:
First Name:OTHELLO
Middle Name:SAYE
Last Name:KWAIDAH
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-4600
Mailing Address - Fax:215-707-9697
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140
Practice Address - Country:US
Practice Address - Phone:215-707-4600
Practice Address - Fax:215-707-9697
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018472363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily