=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790302636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY FRANCES PODMEYER PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2020
-----------------------------------------------------
Last Update Date | 11/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12221 N MOPAC EXPY
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78758-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-901-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15103 FORUM AVE
-----------------------------------------------------
City | PFLUGERVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78660-6252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-524-9715
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA13869
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 9813
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------