Provider Demographics
NPI:1538496989
Name:NWOSU, JACOB C (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:C
Last Name:NWOSU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 LIBERTY PL
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-5715
Mailing Address - Country:US
Mailing Address - Phone:856-776-7540
Mailing Address - Fax:856-776-7512
Practice Address - Street 1:602 LIBERTY PL
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-5700
Practice Address - Country:US
Practice Address - Phone:856-776-7540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP225100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant