Provider Demographics
NPI:1396908950
Name:KELLUM, DENISE (PA-C)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:KELLUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:SOLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7323 MARBACH RD STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78227-1905
Mailing Address - Country:US
Mailing Address - Phone:210-231-2586
Mailing Address - Fax:210-231-2597
Practice Address - Street 1:7323 MARBACH RD STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78227-1905
Practice Address - Country:US
Practice Address - Phone:210-231-2586
Practice Address - Fax:210-231-2583
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1508813494OtherGROUP/BILLING NPI#
TXPA05852OtherPHYSICIAN ASSISTANT LICENSE#
TX1396908950Medicaid
TX363A00000XOtherINDIVIDUAL TAXONOMY