Provider Demographics
NPI:1295246429
Name:OMAR, ABDIFATAH SHARIFF
Entity type:Individual
Prefix:
First Name:ABDIFATAH
Middle Name:SHARIFF
Last Name:OMAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2355 FAIRVIEW AVE N # 182
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2724
Mailing Address - Country:US
Mailing Address - Phone:612-999-8057
Mailing Address - Fax:
Practice Address - Street 1:2355 FAIRVIEW AVE N #182
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:612-999-8057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN$$$$$$$$$OtherSS
MN$$$$$$$$$OtherSS