Provider Demographics
NPI:1619296274
Name:SANDERS, KELLY DEAN (LSA)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:DEAN
Last Name:SANDERS
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7309 WINDING WAY DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76001-2006
Mailing Address - Country:US
Mailing Address - Phone:817-714-9066
Mailing Address - Fax:
Practice Address - Street 1:7309 WINDING WAY DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76001-2006
Practice Address - Country:US
Practice Address - Phone:817-714-9066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX381363AS0400X
TXSA00575246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical