=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154801900
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OMAR RENE BAEZA PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2018
-----------------------------------------------------
Last Update Date | 03/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4122 ECHO MOUNTAIN DR
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77345-2074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 737-216-2977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4122 ECHO MOUNTAIN DR
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77345-2074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 737-216-2977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2105345
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------