Provider Demographics
NPI:1295015105
Name:KISSI, OMER J
Entity Type:Individual
Prefix:
First Name:OMER
Middle Name:J
Last Name:KISSI
Suffix:
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 1:6916 91ST TRL N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55445-3247
Mailing Address - Country:US
Mailing Address - Phone:612-978-4984
Mailing Address - Fax:
Practice Address - Street 1:6916 91ST TRL N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55445-3247
Practice Address - Country:US
Practice Address - Phone:612-978-4984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN376397171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor