Provider Demographics
NPI:1861490831
Name:OSWORTH, JEFFREY R (PA)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:R
Last Name:OSWORTH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 GADY RD
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-9807
Mailing Address - Country:US
Mailing Address - Phone:517-264-1922
Mailing Address - Fax:517-263-6456
Practice Address - Street 1:770 RIVERSIDE AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1476
Practice Address - Country:US
Practice Address - Phone:517-264-1922
Practice Address - Fax:517-263-6456
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001098363AM0700X
MI5601002855363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH51110Medicare UPIN
PR74671Medicare PIN
OH970010477Medicare PIN
MIOH16040021Medicare PIN
MII32772Medicare UPIN