MEDICARE: GAYLON DWAIN KLOPFENSTEIN LSA, CFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	SA00014	TX

General Provider Information

NPI Number	:	1760505184
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAYLON DWAIN KLOPFENSTEIN LSA, CFA

Provider Business Mailing Address
First Line	:	8412 PARK BROOK CT
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-0901
Country	:	US
Telephone Number	:	817-690-8708
Fax Number	:	817-577-5793

Provider Business Practice Location Address
First Line	:	8412 PARK BROOK CT
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-0901
Country	:	US
Telephone Number	:	817-690-8708
Fax Number	:	817-577-5793

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/09/2007
Last Update Date	:	07/08/2007

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