Provider Demographics
NPI:1376282236
Name:WISWALL, KATHARINE JOHANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHARINE
Middle Name:JOHANNA
Last Name:WISWALL
Suffix:
Gender:F
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 1:18777 STONE OAK PKWY APT 528
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4148
Mailing Address - Country:US
Mailing Address - Phone:254-715-7437
Mailing Address - Fax:
Practice Address - Street 1:7939 PAT BOOKER RD STE 130
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-2777
Practice Address - Country:US
Practice Address - Phone:254-715-7437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15665363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA15665OtherTEXAS MEDICAL BOARD
1191480OtherNCCPA