Healthcare Provider Details

I. General information

NPI: 1700514148
Provider Name (Legal Business Name): AUDREY MALCOLM PA-STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2022
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 W SLAUGHTER LN # 310
AUSTIN TX
78749-6507
US

IV. Provider business mailing address

5800 W SLAUGHTER LN # 310
AUSTIN TX
78749-6507
US

V. Phone/Fax

Practice location:
  • Phone: 737-208-1188
  • Fax:
Mailing address:
  • Phone: 737-208-1188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18880
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: