Healthcare Provider Details

I. General information

NPI: 1083322077
Provider Name (Legal Business Name): OMKM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 MILLS LN
FRIENDSWOOD TX
77546-4746
US

IV. Provider business mailing address

709 MILLS LN
FRIENDSWOOD TX
77546-4746
US

V. Phone/Fax

Practice location:
  • Phone: 713-562-0938
  • Fax:
Mailing address:
  • Phone: 713-562-0938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: OMAR A MARTINEZ-QUINONES
Title or Position: MANAGER
Credential:
Phone: 713-562-0938