Provider Demographics
NPI:1740385400
Name:KIZZIE, CARLTON JAY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CARLTON
Middle Name:JAY
Last Name:KIZZIE
Suffix:
Gender:M
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 1:45 NE LOOP 410
Mailing Address - Street 2:STE 850
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-5824
Mailing Address - Country:US
Mailing Address - Phone:210-805-9800
Mailing Address - Fax:210-805-8770
Practice Address - Street 1:423 TREELINE PARK STE 325
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-2060
Practice Address - Country:US
Practice Address - Phone:210-546-1460
Practice Address - Fax:210-546-1459
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03282363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4016123-01Medicaid