Provider Demographics
NPI:1700931631
Name:STAPLES, OMAR COLTRANE (PA)
Entity Type:Individual
Prefix:MR
First Name:OMAR
Middle Name:COLTRANE
Last Name:STAPLES
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 1:5709 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2811
Mailing Address - Country:US
Mailing Address - Phone:510-444-9460
Mailing Address - Fax:510-444-1966
Practice Address - Street 1:5709 MARKET ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94608-2811
Practice Address - Country:US
Practice Address - Phone:510-444-9460
Practice Address - Fax:510-444-1966
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16192363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical