Healthcare Provider Details

I. General information

NPI: 1780105924
Provider Name (Legal Business Name): NATALIE URSULA GONSIOR NICHOLSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15534 RANCH ROAD 620 N STE 100
AUSTIN TX
78717-5277
US

IV. Provider business mailing address

8240 N MOPAC EXPY STE 100
AUSTIN TX
78759-8869
US

V. Phone/Fax

Practice location:
  • Phone: 512-231-1444
  • Fax: 512-828-5511
Mailing address:
  • Phone: 512-687-1970
  • Fax: 512-407-9010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11317
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: