Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225200000X | Physical Therapy Assistant | 2056123 | TX |
NPI | 1003003450 |
---|---|
Provider Name | Omar Antonio Fabian |
First Address | Tyler, TX 75701-6007 |
Second Address | Tyler, TX 75701 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/10/2007 |
Last Update Date | 01/10/2007 |