Provider Demographics
NPI:1548228398
Name:RAYBURN, KELLY ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:RAYBURN
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 1:10922 IRON SPG
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4569
Mailing Address - Country:US
Mailing Address - Phone:210-314-0779
Mailing Address - Fax:
Practice Address - Street 1:1100 WILFORD HALL LOOP
Practice Address - Street 2:
Practice Address - City:JBSA LACKLAND
Practice Address - State:TX
Practice Address - Zip Code:78236-5638
Practice Address - Country:US
Practice Address - Phone:210-314-0779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05332363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX345120501Medicaid
TXP01008379OtherRAILROAD MEDICARE
TXTXB129778Medicare PIN