Provider Demographics
NPI:1073109864
Name:SPADE, ALISSA BOLEK (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:BOLEK
Last Name:SPADE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:ROSALIA
Other - Last Name:BOLEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7712 SENECA FALLS LOOP
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78739-2220
Mailing Address - Country:US
Mailing Address - Phone:512-771-2703
Mailing Address - Fax:
Practice Address - Street 1:11673 JOLLYVILLE RD STE 205
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4211
Practice Address - Country:US
Practice Address - Phone:512-834-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13956207R00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty