Provider Demographics
NPI:1922881143
Name:SASU, KOFI
Entity Type:Individual
Prefix:
First Name:KOFI
Middle Name:
Last Name:SASU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 RAINBOW CIR
Mailing Address - Street 2:
Mailing Address - City:PITTSGROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-9177
Mailing Address - Country:US
Mailing Address - Phone:201-367-8979
Mailing Address - Fax:
Practice Address - Street 1:1129 RAINBOW CIR
Practice Address - Street 2:
Practice Address - City:PITTSGROVE
Practice Address - State:NJ
Practice Address - Zip Code:08318-9177
Practice Address - Country:US
Practice Address - Phone:201-367-8979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14879900363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health