Healthcare Provider Details

I. General information

NPI: 1073109864
Provider Name (Legal Business Name): ALISSA BOLEK SPADE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALISSA ROSALIA BOLEK

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11673 JOLLYVILLE RD STE 205
AUSTIN TX
78759-4211
US

IV. Provider business mailing address

PO BOX 844658
DALLAS TX
75284-4658
US

V. Phone/Fax

Practice location:
  • Phone: 512-834-9999
  • Fax:
Mailing address:
  • Phone: 254-724-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberPA13956
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPA13956
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13956
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: