Provider Demographics
NPI:1295889871
Name:ON, OMAR JAY (PA-C)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:JAY
Last Name:ON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:774 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-1253
Mailing Address - Country:US
Mailing Address - Phone:530-774-2650
Mailing Address - Fax:
Practice Address - Street 1:774 EAST AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1253
Practice Address - Country:US
Practice Address - Phone:530-774-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0PA125480Medicare ID - Type Unspecified
P27217Medicare UPIN