Provider Demographics
NPI:1316228026
Name:LEE, KURT M (PA)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:M
Last Name:LEE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 ROGERS RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-4614
Mailing Address - Country:US
Mailing Address - Phone:210-541-0700
Mailing Address - Fax:210-541-6868
Practice Address - Street 1:1919 ROGERS RD
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4614
Practice Address - Country:US
Practice Address - Phone:210-541-0700
Practice Address - Fax:210-541-6868
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08454363A00000X
FLPA 9106144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX369450701Medicaid