Healthcare Provider Details

I. General information

NPI: 1700376324
Provider Name (Legal Business Name): SHADDE OTHMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E 2ND ST
POMONA CA
91766-1854
US

IV. Provider business mailing address

309 E 2ND ST
POMONA CA
91766-1854
US

V. Phone/Fax

Practice location:
  • Phone: 909-623-9116
  • Fax:
Mailing address:
  • Phone: 909-623-9116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: