Provider Demographics
NPI:1205590726
Name:OMOAREBUN, TONY EHIMARE JR
Entity type:Individual
Prefix:MR
First Name:TONY
Middle Name:EHIMARE
Last Name:OMOAREBUN
Suffix:JR
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 1:11460 RIVERSTONE TRL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-3002
Mailing Address - Country:US
Mailing Address - Phone:651-353-4902
Mailing Address - Fax:
Practice Address - Street 1:11460 RIVERSTONE TRL
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-3002
Practice Address - Country:US
Practice Address - Phone:651-353-4902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty