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General NPI Number Information
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NPI Number | 1689529505
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Entity Type | Individual
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Provider Name | MUKTAR SHILLOW OMAR NP
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Gender | Male
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Dates
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Enumeration Date | 03/04/2026
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Last Update Date | 03/04/2026
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Provider Practice Location Address
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Address Line | 6200 SHINGLE CREEK PKWY STE 260
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City | BROOKLYN CENTER
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State | MN
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Zip | 55430-2128
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Country | US
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Telephone | 763-544-0696
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Fax | 763-544-0984
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Provider Business Mailing Address
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Address Line | 12372 5TH ST NE
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City | MINNEAPOLIS
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State | MN
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Zip | 55434-2644
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Country | US
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Telephone | 612-227-6750
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 13976
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License Number State | MN
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