Healthcare Provider Details

I. General information

NPI: 1790989366
Provider Name (Legal Business Name): ANNE WEATHERLY MAHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5339 N IH 35 STE 100
AUSTIN TX
78723-2558
US

IV. Provider business mailing address

5339 N IH 35 STE 100
AUSTIN TX
78723-2558
US

V. Phone/Fax

Practice location:
  • Phone: 512-628-1898
  • Fax:
Mailing address:
  • Phone: 512-628-1898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberN8684
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN8684
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: