Provider Demographics
NPI:1306078886
Name:LASSWELL, KIMBERLY SUE (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:LASSWELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 CENTRAL PKWY N
Mailing Address - Street 2:SUITE #200
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-5085
Mailing Address - Country:US
Mailing Address - Phone:210-533-9591
Mailing Address - Fax:904-425-2949
Practice Address - Street 1:4360 GRECO DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78222-2725
Practice Address - Country:US
Practice Address - Phone:210-648-8200
Practice Address - Fax:855-392-7988
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-17
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03758363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01430297OtherRR MEDICARE
TX320249102Medicaid
TXPA03758OtherTX LICENSE
TXP01430297OtherRR MEDICARE