Provider Demographics
NPI:1871313726
Name:ABU-WISHAH, OMAR JERAS
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:JERAS
Last Name:ABU-WISHAH
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 1:1925 SECLUSION PT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-7975
Mailing Address - Country:US
Mailing Address - Phone:909-680-0404
Mailing Address - Fax:
Practice Address - Street 1:157 FONTAINE BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80911-2110
Practice Address - Country:US
Practice Address - Phone:909-680-0404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor