Provider Demographics
NPI:1275366346
Name:KONZELMAN, OWEN (PA-C)
Entity type:Individual
Prefix:
First Name:OWEN
Middle Name:
Last Name:KONZELMAN
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 1:721 WINCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3432
Mailing Address - Country:US
Mailing Address - Phone:610-545-3722
Mailing Address - Fax:
Practice Address - Street 1:2201 CHAPEL AVE W
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-2048
Practice Address - Country:US
Practice Address - Phone:856-488-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-23
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00882200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant