Provider Demographics
NPI:1730115577
Name:SANDHU, IFTIKHAR A (PA-C)
Entity Type:Individual
Prefix:
First Name:IFTIKHAR
Middle Name:A
Last Name:SANDHU
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4303
Mailing Address - Country:US
Mailing Address - Phone:405-285-7222
Mailing Address - Fax:405-285-7227
Practice Address - Street 1:2212 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4303
Practice Address - Country:US
Practice Address - Phone:405-285-7222
Practice Address - Fax:405-285-7227
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100224630AMedicaid