MEDICARE: MUKTAR SHILLOW OMAR NP

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	363LF0000X	Family Nurse Practitioner	13976	MN

General Provider Information

NPI Number	:	1689529505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MUKTAR SHILLOW OMAR NP

Provider Business Mailing Address
First Line	:	12372 5TH ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55434-2644
Country	:	US
Telephone Number	:	612-227-6750
Fax Number	:

Provider Business Practice Location Address
First Line	:	6200 SHINGLE CREEK PKWY STE 260
Second Line	:
City	:	BROOKLYN CENTER
State	:	MN
Zip	:	55430-2128
Country	:	US
Telephone Number	:	763-544-0696
Fax Number	:	763-544-0984

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

Provider Enumeration Date	:	03/04/2026
Last Update Date	:	03/04/2026

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