MEDICARE: MS. KEKELI DIANE OMINIRA AMARA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	025399	NY

General Provider Information

NPI Number	:	1528671831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KEKELI DIANE OMINIRA AMARA PA-C

Provider Business Mailing Address
First Line	:	PO BOX 2669
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10163-2669
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1535 ELKTON PL
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45224-2517
Country	:	US
Telephone Number	:	513-919-6463
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2020
Last Update Date	:	08/26/2020

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