Provider Demographics
NPI:1316705320
Name:OMOT, PETER KAGA II
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:KAGA
Last Name:OMOT
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 WILSON AVE NE STE 15
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-0403
Mailing Address - Country:US
Mailing Address - Phone:320-443-4418
Mailing Address - Fax:
Practice Address - Street 1:22 WILSON AVE NE STE 15
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56304-0403
Practice Address - Country:US
Practice Address - Phone:320-443-4418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNK811182269510343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)