Provider Demographics
NPI:1245939495
Name:OMOTO, RAPHAEL (CNP)
Entity type:Individual
Prefix:MR
First Name:RAPHAEL
Middle Name:
Last Name:OMOTO
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:MR
Other - First Name:RAPHAEL
Other - Middle Name:
Other - Last Name:OMOTO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CNP
Mailing Address - Street 1:7420 UNITY AVE N STE 310C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-3162
Mailing Address - Country:US
Mailing Address - Phone:612-212-2595
Mailing Address - Fax:
Practice Address - Street 1:7420 UNITY AVE N STE 310C
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3162
Practice Address - Country:US
Practice Address - Phone:612-212-2595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9968363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health