Provider Demographics
NPI:1477922474
Name:FONSECA, MICHELLE SHEREE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:SHEREE
Last Name:FONSECA
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 1:3110 NOGALITOS STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78225-2337
Mailing Address - Country:US
Mailing Address - Phone:210-533-0257
Mailing Address - Fax:
Practice Address - Street 1:9811 HUEBNER RD BLDG 2
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3255
Practice Address - Country:US
Practice Address - Phone:210-561-8169
Practice Address - Fax:210-561-8178
Is Sole Proprietor?:No
Enumeration Date:2015-09-20
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXPA10964363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA10964OtherLICENSE