Provider Demographics
NPI:1932149390
Name:OMOTO, GENE T (PA)
Entity Type:Individual
Prefix:MR
First Name:GENE
Middle Name:T
Last Name:OMOTO
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:P.O. BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:16120 WEST DODGE ROAD
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:38118
Practice Address - Country:US
Practice Address - Phone:402-354-0707
Practice Address - Fax:402-354-0711
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1205363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00353556OtherRAILROAD MEDICARE
NE38642OtherBCBS
NE280196Medicare PIN
NE099099036Medicare PIN
Q70581Medicare UPIN