Provider Demographics
NPI:1831182005
Name:LYSSY, KATHLEEN JANE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:JANE
Last Name:LYSSY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 BANDERA RD
Mailing Address - Street 2:403
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-1652
Mailing Address - Country:US
Mailing Address - Phone:210-256-9500
Mailing Address - Fax:210-256-8720
Practice Address - Street 1:6100 BANDERA RD
Practice Address - Street 2:403
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-1652
Practice Address - Country:US
Practice Address - Phone:210-256-9500
Practice Address - Fax:210-256-8720
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8039207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0086EUOtherBLUE CROSS BLUE SHIELD
TXG17104Medicare UPIN
TX00959LMedicare ID - Type Unspecified