Healthcare Provider Details

I. General information

NPI: 1013647817
Provider Name (Legal Business Name): OMAR AHMED MOHAMED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 N WYOMING AVE
KANSAS CITY MO
64118-8351
US

IV. Provider business mailing address

7100 N WYOMING AVE
KANSAS CITY MO
64118-8351
US

V. Phone/Fax

Practice location:
  • Phone: 650-229-8557
  • Fax:
Mailing address:
  • Phone: 650-229-8557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number2021016270
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number2021016270
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: