Provider Demographics
NPI:1639189970
Name:OMAMOGHO, ROSE G (PA-C)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:G
Last Name:OMAMOGHO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S COULTER ST STE 6
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1790
Mailing Address - Country:US
Mailing Address - Phone:806-467-9777
Mailing Address - Fax:806-467-9799
Practice Address - Street 1:1500 S COULTER ST STE 6
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1790
Practice Address - Country:US
Practice Address - Phone:806-467-9777
Practice Address - Fax:806-467-9799
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL8509OtherLAB
TX143454100OtherFIRST CARE
TX8N8539OtherBCBS
TX8N8539OtherBCBS
TXQ44762Medicare UPIN
TX4418920001Medicare NSC
TX8D5084Medicare PIN