Provider Demographics
NPI:1487238721
Name:OMER, SHANE (DPT)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:OMER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 GOLD KEY LN
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6178
Mailing Address - Country:US
Mailing Address - Phone:907-350-6907
Mailing Address - Fax:
Practice Address - Street 1:304 W EVERGREEN AVE STE 101
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6970
Practice Address - Country:US
Practice Address - Phone:907-745-8686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
AK194449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist