Provider Demographics
NPI:1497055685
Name:OUM, RORTANA (AAC)
Entity Type:Individual
Prefix:MR
First Name:RORTANA
Middle Name:
Last Name:OUM
Suffix:
Gender:M
Credentials:AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13560 CYPRESS GLEN LN UNIT 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-1116
Mailing Address - Country:US
Mailing Address - Phone:913-661-4676
Mailing Address - Fax:
Practice Address - Street 1:3100 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4613
Practice Address - Country:US
Practice Address - Phone:813-615-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA68367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA68OtherAAC