Provider Demographics
NPI:1275251944
Name:CARBAJAL, OMAR (CRNA)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:CARBAJAL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8769 PRINCE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-1257
Mailing Address - Country:US
Mailing Address - Phone:310-569-3529
Mailing Address - Fax:
Practice Address - Street 1:2767 OLIVE HWY
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-6118
Practice Address - Country:US
Practice Address - Phone:530-533-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001821367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered