Provider Demographics
NPI:1710537832
Name:ABUOMRAN, LAITH ABDALFATTAH
Entity Type:Individual
Prefix:MR
First Name:LAITH
Middle Name:ABDALFATTAH
Last Name:ABUOMRAN
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 1:3464 COLONIAL AVE APT N87
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-4540
Mailing Address - Country:US
Mailing Address - Phone:540-656-1393
Mailing Address - Fax:
Practice Address - Street 1:6318 PETERS CREEK RD UNIT A8
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-4059
Practice Address - Country:US
Practice Address - Phone:540-656-1393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA100037766347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle