Provider Demographics
NPI:1750688594
Name:NWOSU, KENNETH (DPT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:NWOSU
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CREDIT UNION WAY FL 3
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:1290 TREMONT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-3432
Practice Address - Country:US
Practice Address - Phone:617-989-3100
Practice Address - Fax:617-858-2494
Is Sole Proprietor?:No
Enumeration Date:2011-02-14
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110088251AMedicaid
MA002071302OtherMEDICARE PTAN