Basic Information
| Provider Information | |||||||||
| NPI: | 1649399619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMAR | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARTER | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PTA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5059 QUAIL RUN RD | ||||||||
| Address2: | APT 65 | ||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925070406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193688630 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 64 DANBURY RD | ||||||||
| Address2: | |||||||||
| City: | WILTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068974429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002780332 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 04/26/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | AT9479 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.