Provider Demographics
NPI:1073632410
Name:KELLENBERGER, DAVID ANDREW (PA, RD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ANDREW
Last Name:KELLENBERGER
Suffix:
Gender:M
Credentials:PA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 HOSPITAL DR STE 140
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-2415
Mailing Address - Country:US
Mailing Address - Phone:903-201-6405
Mailing Address - Fax:
Practice Address - Street 1:401 HOSPITAL DR STE 140
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-2415
Practice Address - Country:US
Practice Address - Phone:903-201-6405
Practice Address - Fax:903-641-7502
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT81736133V00000X
TXPA04525363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX355695308Medicaid
TX1G0179OtherMEDICARE