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General NPI Number Information
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NPI Number | 1619296274
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Entity Type | Individual
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Provider Name | KELLY DEAN SANDERS LSA
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Gender | Male
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Dates
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Enumeration Date | 05/21/2010
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Last Update Date | 03/28/2020
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Provider Practice Location Address
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Address Line | 7309 WINDING WAY DR
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City | ARLINGTON
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State | TX
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Zip | 76001-2006
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Country | US
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Telephone | 817-714-9066
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Fax |
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Provider Business Mailing Address
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Address Line | 7309 WINDING WAY DR
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City | ARLINGTON
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State | TX
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Zip | 76001-2006
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Country | US
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Telephone | 817-714-9066
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 381
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | SA00575
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License Number State | TX
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