Provider Demographics
NPI:1760256457
Name:NWOSU, MICHAEL C (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:NWOSU
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 1:102 BROOKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT ARLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07856-1364
Mailing Address - Country:US
Mailing Address - Phone:973-723-7806
Mailing Address - Fax:
Practice Address - Street 1:266 HARRISTOWN RD STE 200
Practice Address - Street 2:
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-3354
Practice Address - Country:US
Practice Address - Phone:201-445-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00409800225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant