Provider Demographics
NPI:1376282236
Name:WISWALL, KATHARINE JOHANNA (PA-C)
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:JOHANNA
Last Name:WISWALL
Suffix:
Gender:F
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 1:903 W MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-0903
Mailing Address - Country:US
Mailing Address - Phone:210-358-3400
Mailing Address - Fax:
Practice Address - Street 1:903 W MARTIN ST # MS 49-2
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-0903
Practice Address - Country:US
Practice Address - Phone:201-358-5437
Practice Address - Fax:210-358-5890
Is Sole Proprietor?:No
Enumeration Date:2022-05-31
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15665363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1191480OtherNCCPA
TXPA15665OtherTEXAS MEDICAL BOARD