Provider Demographics
NPI:1720370760
Name:SEDERHOLM, LAUREN NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:NICOLE
Last Name:SEDERHOLM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5656 BEE CAVE ROAD
Mailing Address - Street 2:SUITE J201
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746
Mailing Address - Country:US
Mailing Address - Phone:512-446-9486
Mailing Address - Fax:512-597-0402
Practice Address - Street 1:5656 BEE CAVE ROAD
Practice Address - Street 2:SUITE J201
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746
Practice Address - Country:US
Practice Address - Phone:512-446-9486
Practice Address - Fax:512-597-0402
Is Sole Proprietor?:No
Enumeration Date:2011-05-10
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07293363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287558505Medicaid
TX318111YK4EMedicare PIN