Provider Demographics
NPI:1598193583
Name:OMMUNDSEN, MICHAEL STANLEY (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STANLEY
Last Name:OMMUNDSEN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-5928
Mailing Address - Country:US
Mailing Address - Phone:919-535-8758
Mailing Address - Fax:919-535-3271
Practice Address - Street 1:704 N JUDD PKWY NE STE 100
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-1989
Practice Address - Country:US
Practice Address - Phone:919-896-7158
Practice Address - Fax:919-896-7208
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01477300225100000X
NCP14946225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist