Provider Demographics
NPI:1487652715
Name:OSBORNE, MISTY A (PA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:A
Last Name:OSBORNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N SUMMIT ST FL 7
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3834
Practice Address - Country:US
Practice Address - Phone:419-531-8558
Practice Address - Fax:419-531-8798
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5001549363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0070838Medicaid
OH76211Medicare PIN
OH970017856Medicare PIN
OH25422Medicare UPIN