Provider Demographics
NPI:1568852820
Name:LIEPSHUTZ, KELLY M (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:LIEPSHUTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MCCOYD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09655363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX352128801Medicaid
TX449990YKQHMedicare PIN