Healthcare Provider Details

I. General information

NPI: 1033086699
Provider Name (Legal Business Name): MOHAMUD SHAMUN OMAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2025
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 DUTTON ST UNIT B
MANCHESTER NH
03104-5080
US

IV. Provider business mailing address

29 DUTTON ST UNIT B
MANCHESTER NH
03104-5080
US

V. Phone/Fax

Practice location:
  • Phone: 207-420-7465
  • Fax:
Mailing address:
  • Phone: 207-420-7465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code342000000X
TaxonomyTransportation Network Company
License NumberNHL18369960
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: