Healthcare Provider Details

I. General information

NPI: 1366569402
Provider Name (Legal Business Name): RICHARD SEAN OMSBERG PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11410 JOLLYVILLE RD STE 1101
AUSTIN TX
78759-4093
US

IV. Provider business mailing address

8240 N MOPAC EXPY STE 100
AUSTIN TX
78759-8869
US

V. Phone/Fax

Practice location:
  • Phone: 512-231-1444
  • Fax:
Mailing address:
  • Phone: 512-687-1950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03654
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: