Provider Demographics
NPI:1184468969
Name:OMAR, FARDOWSA A I (HIGHT SHOOL DIPLOMA)
Entity type:Individual
Prefix:
First Name:FARDOWSA
Middle Name:A
Last Name:OMAR
Suffix:I
Gender:F
Credentials:HIGHT SHOOL DIPLOMA
Other - Prefix:
Other - First Name:SALMA
Other - Middle Name:A
Other - Last Name:OMAR
Other - Suffix:I
Other - Last Name Type:Other Name
Other - Credentials:HIGH SCHOOL DIPLOMA
Mailing Address - Street 1:6320 PENN AVE S
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-1139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6320 PENN AVE S
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-1139
Practice Address - Country:US
Practice Address - Phone:612-433-6740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician