Healthcare Provider Details

I. General information

NPI: 1114354404
Provider Name (Legal Business Name): OMAYRA MONTALVO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MAIN ST
BRAWLEY CA
92227-2630
US

IV. Provider business mailing address

1136 CALLE DEL SOL
BRAWLEY CA
92227-7747
US

V. Phone/Fax

Practice location:
  • Phone: 760-344-6471
  • Fax: 760-344-8410
Mailing address:
  • Phone: 760-344-9951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number23182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: