Provider Demographics
NPI:1114354404
Name:MONTALVO, OMAYRA (PA)
Entity Type:Individual
Prefix:
First Name:OMAYRA
Middle Name:
Last Name:MONTALVO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 CALLE DEL SOL
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-7747
Mailing Address - Country:US
Mailing Address - Phone:760-344-9951
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2630
Practice Address - Country:US
Practice Address - Phone:760-344-6471
Practice Address - Fax:760-344-8410
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23182363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1649269747Medicaid