Provider Demographics
NPI:1366569402
Name:OMSBERG, RICHARD SEAN (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:SEAN
Last Name:OMSBERG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8240 N MOPAC EXPY STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8869
Mailing Address - Country:US
Mailing Address - Phone:512-687-1950
Mailing Address - Fax:
Practice Address - Street 1:11410 JOLLYVILLE RD STE 1101
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4093
Practice Address - Country:US
Practice Address - Phone:512-231-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03654363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX202037201Medicaid
TXP00708734OtherRAILROAD MEDICARE
TX8Y9920OtherBLUE CROSS BLUE SHIELD
TXP82663Medicare UPIN
TX202037201Medicaid
8B8870Medicare PIN