Individual
KELLY ANNE RAYBURN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
1100 WILFORD HALL LOOP, JBSA LACKLAND, TX 78236-5638
(210) 314-0779
Mailing address
10922 IRON SPG, HELOTES, TX 78023-4569
(210) 314-0779
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
PA05332
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
345120501
—
TX
01
—
P01008379
RAILROAD MEDICARE
TX
Enumeration date
05/02/2006
Last updated
12/02/2019
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