Basic Information
| Provider Information | |||||||||
| NPI: | 1376696971 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | JAN | ||||||||
| FirstName: | OMAR | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4351 E. LOHMAN AVENUE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755329755 | ||||||||
| FaxNumber: | 5755328881 | ||||||||
| Practice Location | |||||||||
| Address1: | 4351 E LOHMAN AVE STE 301 | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880118262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755329755 | ||||||||
| FaxNumber: | 5755328881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2005-0019 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 588571 | 05 | NM | MEDICAID |