MEDICARE: JASPER EVANS OMOLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN.373941	OH

General Provider Information

NPI Number	:	1417229964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASPER EVANS OMOLO

Provider Business Mailing Address
First Line	:	7015 BASCOMBE DR
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-2905
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7015 BASCOMBE DR
Second Line	:
City	:	HUBER HEIGHTS
State	:	OH
Zip	:	45424-2905
Country	:	US
Telephone Number	:	937-344-4451
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2012
Last Update Date	:	01/30/2012

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