Provider Demographics
NPI:1366817306
Name:O'MARRA, ASIYA RAIFOVNA (PA-C)
Entity type:Individual
Prefix:
First Name:ASIYA
Middle Name:RAIFOVNA
Last Name:O'MARRA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ASIYA
Other - Middle Name:RAIFOVNA
Other - Last Name:FATYKHOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:23 CROSSROADS DR STE 400
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5490
Mailing Address - Country:US
Mailing Address - Phone:410-356-2626
Mailing Address - Fax:410-356-8945
Practice Address - Street 1:410 MALCOLM DR STE E
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6160
Practice Address - Country:US
Practice Address - Phone:410-876-9300
Practice Address - Fax:410-876-4495
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD472124YVZMedicare PIN
MD466419YWV2Medicare PIN
MD472124ZDDBMedicare PIN