Provider Demographics
NPI:1083452940
Name:MENDOZA CHAVEZ, OMAR (RN)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:MENDOZA CHAVEZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 PERA DR
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-3024
Mailing Address - Country:US
Mailing Address - Phone:831-288-4831
Mailing Address - Fax:
Practice Address - Street 1:339 PAJARO ST
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3400
Practice Address - Country:US
Practice Address - Phone:831-800-7530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95379295163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse