Provider Demographics
NPI:1447880703
Name:WISWELL, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WISWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5623 HAMILTON WOLFE APT 134
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78240-4021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3333 RESEARCH PLZ
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78235-5154
Practice Address - Country:US
Practice Address - Phone:210-297-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant