Provider Demographics
NPI:1255483632
Name:DUENES, OMAR (PA)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:DUENES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 W PLACER DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-1833
Mailing Address - Country:US
Mailing Address - Phone:626-622-8373
Mailing Address - Fax:
Practice Address - Street 1:2625 W ALAMEDA AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4806
Practice Address - Country:US
Practice Address - Phone:818-841-2625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18076363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACT626WMedicare PIN
CACT626YMedicare PIN
CACB247432Medicare PIN
CACT626XMedicare PIN
CACT626VMedicare PIN
CACB217176Medicare PIN