Provider Demographics
NPI:1891202131
Name:ZOTOGLO, KOSSI MAWOULI (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KOSSI
Middle Name:MAWOULI
Last Name:ZOTOGLO
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 1:3254 S 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3576
Mailing Address - Country:US
Mailing Address - Phone:402-681-1036
Mailing Address - Fax:
Practice Address - Street 1:4101 WOOLWORTH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1850
Practice Address - Country:US
Practice Address - Phone:402-995-3462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA090410363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical