Provider Demographics
NPI:1891234340
Name:RAZACK, OMAR CHRISTOPHER (PA-C)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:CHRISTOPHER
Last Name:RAZACK
Suffix:
Gender:M
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 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:954-205-7156
Mailing Address - Fax:
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006392363A00000X
FL9110188363A00000X
CA55767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant