Provider Demographics
NPI:1750576617
Name:ALPHONSE, OSWALD JUNIOR (PA-C)
Entity type:Individual
Prefix:MR
First Name:OSWALD
Middle Name:JUNIOR
Last Name:ALPHONSE
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:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-223-2847
Practice Address - Street 1:3801 S KANNER HWY STE 200
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-4801
Practice Address - Country:US
Practice Address - Phone:772-223-4978
Practice Address - Fax:772-223-2847
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY02YXOtherFL BLUE
FL293039100Medicaid
FLY02YXOtherFL BLUE