Basic Information
Provider Information
NPI: 1003003450
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FABIAN
FirstName: OMAR
MiddleName: ANTONIO
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NameSuffix:  
Credential:  
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Mailing Information
Address1: 2717 ROLLINGWOOD DR
Address2:  
City: TYLER
State: TX
PostalCode: 757016007
CountryCode: US
TelephoneNumber: 9032451844
FaxNumber:  
Practice Location
Address1: 2717 ROLLINGWOOD
Address2:  
City: TYLER
State: TX
PostalCode: 75701
CountryCode: US
TelephoneNumber: 9032451844
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/01/2007
LastUpdateDate: 10/01/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
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IsSoleProprietor: N
IsOrganizationSubpart:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225200000X2056123TXY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant 

No ID Information.


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