Healthcare Provider Details

I. General information

NPI: 1619130440
Provider Name (Legal Business Name): DEBORAH CERESA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10001 S IH 35
AUSTIN TX
78747-1701
US

IV. Provider business mailing address

10001 S IH 35
AUSTIN TX
78747-1701
US

V. Phone/Fax

Practice location:
  • Phone: 512-440-0555
  • Fax: 512-448-1113
Mailing address:
  • Phone: 512-440-0555
  • Fax: 512-448-1113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA08544
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: