Healthcare Provider Details

I. General information

NPI: 1275107021
Provider Name (Legal Business Name): NASRALDIN OMER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 KNORR ST FL 1
PHILADELPHIA PA
19111-4809
US

IV. Provider business mailing address

1031 KNORR ST FL 1
PHILADELPHIA PA
19111-4809
US

V. Phone/Fax

Practice location:
  • Phone: 215-554-9749
  • Fax:
Mailing address:
  • Phone: 215-554-9749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number7090305
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: