Provider Demographics
NPI:1275385270
Name:OMAR, RAVEN ALISE (PA-C)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:ALISE
Last Name:OMAR
Suffix:
Gender:F
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 1:7637 WIND GAP LN
Mailing Address - Street 2:
Mailing Address - City:PINSON
Mailing Address - State:AL
Mailing Address - Zip Code:35126-4001
Mailing Address - Country:US
Mailing Address - Phone:205-901-8255
Mailing Address - Fax:
Practice Address - Street 1:48 MEDICAL PARK DR E STE 458
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3473
Practice Address - Country:US
Practice Address - Phone:205-838-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant