Basic Information
| Provider Information | |||||||||
| NPI: | 1245202738 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OMONDE | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 N EDEN DR | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278893114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529400602 | ||||||||
| FaxNumber: | 2529400605 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 W. MARTIN LUTHER KNG JR. DRIVE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529400602 | ||||||||
| FaxNumber: | 2529400605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 04/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 102580 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 341871 | 01 | NC | FQHC MEDICARE | OTHER | 344591A/344591C | 01 | NC | FQHC MEDICAID | OTHER | 344591C | 05 | NC | MEDICAID |