Provider Demographics
NPI:1376696971
Name:JAN, OMAR (PA)
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:
Last Name:JAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4351 E. LOHMAN AVENUE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011
Mailing Address - Country:US
Mailing Address - Phone:575-532-9755
Mailing Address - Fax:575-532-8881
Practice Address - Street 1:4351 E LOHMAN AVE STE 301
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8262
Practice Address - Country:US
Practice Address - Phone:575-532-9755
Practice Address - Fax:575-532-8881
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1889363A00000X
NMPA2005-0019363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1376696971Medicaid
NM588571Medicaid
NM346725501Medicare PIN