=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164685160
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA LYNN WIATREK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2008
-----------------------------------------------------
Last Update Date | 05/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12201 RENFERT WAY SUITE 240
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-5354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-498-4850
-----------------------------------------------------
Fax | 512-491-8387
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 911230
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75391-1230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-997-8000
-----------------------------------------------------
Fax | 972-234-2987
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086X0206X
-----------------------------------------------------
Taxonomy Name | Surgical Oncology Physician
-----------------------------------------------------
License Number | M7757
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | M7757
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------