Healthcare Provider Details

I. General information

NPI: 1487569265
Provider Name (Legal Business Name): OMAR MOHAMMED TUTAKHIL FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1076 NW VARNISH LN
REDMOND OR
97756-2182
US

IV. Provider business mailing address

1076 NW VARNISH LN
REDMOND OR
97756-2182
US

V. Phone/Fax

Practice location:
  • Phone: 775-530-6971
  • Fax:
Mailing address:
  • Phone: 775-530-6971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10065064
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: