Basic Information
| Provider Information | |||||||||
| NPI: | 1164747648 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALSAM | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | JAMES METTES | ||||||||
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| Credential: | MPAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4502 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104509000 | ||||||||
| FaxNumber: | 2104504903 | ||||||||
| Practice Location | |||||||||
| Address1: | 4502 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782294402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103582078 | ||||||||
| FaxNumber: | 2103581972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2010 | ||||||||
| LastUpdateDate: | 03/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA06697 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 219926701 | 05 | TX | MEDICAID | 219926702 | 01 | TX | CSHCN | OTHER |