Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | PA13956 | TX |
N | 207R00000X | Internist | PA13956 | TX |
N | 111NI0900X | Internist | PA13956 | TX |
NPI | 1073109864 |
---|---|
Provider Name | Alissa Bolek Spade |
First Address | Austin, TX 78739-2220 |
Second Address | Austin, TX 78759-4211 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2020 |
Last Update Date | 15/12/2020 |