Provider Demographics
NPI:1508181488
Name:SPONHALTZ, KELLY JAMES (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JAMES
Last Name:SPONHALTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78291-0087
Mailing Address - Country:US
Mailing Address - Phone:210-358-9500
Mailing Address - Fax:210-358-9183
Practice Address - Street 1:903 W MARTIN ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-0903
Practice Address - Country:US
Practice Address - Phone:210-358-3441
Practice Address - Fax:210-358-5944
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214265502Medicaid
TX214265503OtherCSHCN
TX214265502Medicaid