MEDICARE: MR. OMAR COLTRANE STAPLES P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA16192	CA

General Provider Information

NPI Number	:	1700931631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OMAR COLTRANE STAPLES P.A.

Provider Business Mailing Address
First Line	:	5709 MARKET ST
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94608-2811
Country	:	US
Telephone Number	:	510-444-9460
Fax Number	:	510-444-1966

Provider Business Practice Location Address
First Line	:	5709 MARKET ST
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94608-2811
Country	:	US
Telephone Number	:	510-444-9460
Fax Number	:	510-444-1966

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/08/2007

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