Provider Demographics
NPI:1487705471
Name:OSAZE, EBUN (PA)
Entity type:Individual
Prefix:
First Name:EBUN
Middle Name:
Last Name:OSAZE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2529
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:217-383-4752
Practice Address - Street 1:311 W. FAIRCHILD STREET
Practice Address - Street 2:FAMILY MEDICINE/CONVENIENT CARE
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-431-7650
Practice Address - Fax:217-431-7634
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85001739363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00156941OtherRAILROAD
IL0533210001OtherDMERC
ILK06839Medicare PIN
Q16546Medicare UPIN
ILQ16546Medicare UPIN
IL6447860014Medicare NSC
ILIL3270494Medicare PIN