Provider Demographics
NPI:1245202738
Name:OMONDE, PETER II (PA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:OMONDE
Suffix:II
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N EDEN DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3114
Mailing Address - Country:US
Mailing Address - Phone:252-940-0602
Mailing Address - Fax:252-940-0605
Practice Address - Street 1:120 W. MARTIN LUTHER KNG JR. DRIVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889
Practice Address - Country:US
Practice Address - Phone:252-940-0602
Practice Address - Fax:252-940-0605
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102580363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC341871OtherFQHC MEDICARE
NC344591A/344591COtherFQHC MEDICAID
NC344591CMedicaid
NC344591CMedicaid