Provider Demographics
NPI:1235589854
Name:OMAR, BASHIR I
Entity Type:Individual
Prefix:MR
First Name:BASHIR
Middle Name:
Last Name:OMAR
Suffix:I
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 1:2426 PARK AVE NW APT 309
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-9255
Mailing Address - Country:US
Mailing Address - Phone:612-644-4582
Mailing Address - Fax:
Practice Address - Street 1:2426 PARK AVE # 309
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021
Practice Address - Country:US
Practice Address - Phone:612-644-4582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNS149126721414171R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter