Provider Demographics
NPI:1619733557
Name:SHUKRI, OMAR
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:
Last Name:SHUKRI
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 1:1701 AMERICAN BLVD E STE 16
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1401
Mailing Address - Country:US
Mailing Address - Phone:612-605-1621
Mailing Address - Fax:612-605-1631
Practice Address - Street 1:1701 AMERICAN BLVD E STE 16
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1401
Practice Address - Country:US
Practice Address - Phone:612-605-1621
Practice Address - Fax:612-605-1631
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNW513-266-982-909172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver