MEDICARE: MR. OMAR JAN 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	363A00000X	Physician Assistant	1889	WI
2	363A00000X	Physician Assistant	PA2005-0019	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376696971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. OMAR JAN P.A.

Provider Business Mailing Address
First Line	:	4351 E. LOHMAN AVENUE
Second Line	:	SUITE 301
City	:	LAS CRUCES
State	:	NM
Zip	:	88011
Country	:	US
Telephone Number	:	575-532-9755
Fax Number	:	575-532-8881

Provider Business Practice Location Address
First Line	:	4351 E LOHMAN AVE STE 301
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-8262
Country	:	US
Telephone Number	:	575-532-9755
Fax Number	:	575-532-8881

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

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	11/15/2023

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Directions to “ MR. OMAR JAN P.A.” Practice Location

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