Provider Demographics
NPI:1811920564
Name:OMAN, MICHELLE RENEE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:OMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 HIGHWAY 110
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MN
Mailing Address - Zip Code:55705-1522
Mailing Address - Country:US
Mailing Address - Phone:218-229-3311
Mailing Address - Fax:
Practice Address - Street 1:405 W 3RD AVE N
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MN
Practice Address - Zip Code:55705-1247
Practice Address - Country:US
Practice Address - Phone:218-229-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN43752207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN240765500Medicaid
MN080012427Medicare PIN
MN240765500Medicaid