Provider Demographics
NPI:1144662909
Name:JACK, OMAR DWAYNE (DO, PA-C)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:DWAYNE
Last Name:JACK
Suffix:
Gender:M
Credentials:DO, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 GOODELL ST STE 550
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1258
Mailing Address - Country:US
Mailing Address - Phone:716-829-6108
Mailing Address - Fax:
Practice Address - Street 1:77 GOODELL ST STE 550
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1258
Practice Address - Country:US
Practice Address - Phone:716-829-6108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1109724363A00000X
PAMA062538363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical