Provider Demographics
NPI:1073283693
Name:WETHERHOLT, KENNETH MICHAEL (CSFA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:WETHERHOLT
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8626 TESORO DR STE 502
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217-6217
Mailing Address - Country:US
Mailing Address - Phone:210-496-2222
Mailing Address - Fax:
Practice Address - Street 1:8626 TESORO DR STE 502
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217-6217
Practice Address - Country:US
Practice Address - Phone:210-496-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
194476246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant