Provider Demographics
NPI:1164144275
Name:BOUSO, OMAR (CSA)
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:
Last Name:BOUSO
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6932 SW 18TH CT
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33068-4328
Mailing Address - Country:US
Mailing Address - Phone:954-204-2151
Mailing Address - Fax:
Practice Address - Street 1:6932 SW 18TH CT
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33068-4328
Practice Address - Country:US
Practice Address - Phone:954-204-2151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI22-533246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant