Basic Information
| Provider Information | |||||||||
| NPI: | 1497055685 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OUM | ||||||||
| FirstName: | RORTANA | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Credential: | AAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13560 CYPRESS GLEN LN UNIT 201 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336371116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136614676 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3100 E FLETCHER AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336134613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136157848 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2010 | ||||||||
| LastUpdateDate: | 10/22/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | AA68 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | AA68 | 01 | FL | AAC | OTHER |