Active NPI
Omar Dwayne Jack, DO, PA-C
- Student in an Organized Health Care Education/Training Program
- Buffalo, NY
National Provider Identifier
1144662909
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Student in an Organized Health Care Education/Training Program
- Practice address
- 77 Goodell St Ste 550
Buffalo, NY 14203-1258 - Phone
- (716) 829-6108
- NPI assigned
- Jul 22, 2013
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 1109724 | GA | |
| Medical Physician Assistant | 363AM0700X | MA062538 | PA | |
| Student in an Organized Health Care Education/Training Program | 390200000X | Primary |
Addresses
Primary practice location
77 Goodell St Ste 550
Buffalo, NY 14203-1258
Mailing address
77 Goodell St Ste 550
Buffalo, NY 14203-1258
Phone (716) 829-6108
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Osteopathy, Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1109724 | GA | MD | Physician Assistant |
| MA062538 | PA | MD | Medical Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1374451200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1711411200000",
"number": "1144662909",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "77 GOODELL ST STE 550",
"city": "BUFFALO",
"state": "NY",
"postal_code": "142031258",
"telephone_number": "716-829-6108"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "77 GOODELL ST STE 550",
"city": "BUFFALO",
"state": "NY",
"postal_code": "142031258",
"telephone_number": "716-829-6108"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACK",
"first_name": "OMAR",
"middle_name": "DWAYNE",
"credential": "DO, PA-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2013-07-22",
"last_updated": "2024-03-26",
"certification_date": "2024-03-26",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "GA",
"license": "1109724",
"primary": false
},
{
"code": "363AM0700X",
"taxonomy_group": "",
"desc": "Physician Assistant, Medical",
"state": "PA",
"license": "MA062538",
"primary": false
},
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Buffalo, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 26, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.