Provider Demographics
NPI:1235834300
Name:LE-PHAM, KELLY THI (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:THI
Last Name:LE-PHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:THI
Other - Last Name:LE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:525 OAK CENTRE DR STE 140
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3916
Mailing Address - Country:US
Mailing Address - Phone:210-504-3650
Mailing Address - Fax:
Practice Address - Street 1:525 OAK CENTRE DR STE 140
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3916
Practice Address - Country:US
Practice Address - Phone:210-504-3650
Practice Address - Fax:210-519-3045
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA17256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program