Provider Demographics
NPI:1598102832
Name:OMAR, RADWA CLARISSA (APRN)
Entity Type:Individual
Prefix:
First Name:RADWA
Middle Name:CLARISSA
Last Name:OMAR
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2898
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-4898
Mailing Address - Country:US
Mailing Address - Phone:606-248-7778
Mailing Address - Fax:606-248-7787
Practice Address - Street 1:3602 CUMBERLAND AVE STE B102
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2614
Practice Address - Country:US
Practice Address - Phone:606-248-7778
Practice Address - Fax:606-248-7787
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008054363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYMM3197527Medicaid
KYPENDINGMedicare PIN