Healthcare Provider Details

I. General information

NPI: 1952940025
Provider Name (Legal Business Name): GERARD IDRISSA OMARI RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 01/06/2020
Certification Date: 01/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5844 JERSEY AVENUE NORTH
CRYSTAL MN
55428
US

IV. Provider business mailing address

5844 JERSEY AVENUE NORTH
CRYSTAL MN
55428
US

V. Phone/Fax

Practice location:
  • Phone: 763-614-0355
  • Fax:
Mailing address:
  • Phone: 763-614-0355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2427542
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: