Active NPI
Ladera Park Dermatology PA
- Dermatology Physician
- Austin, TX
National Provider Identifier
1225567704
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dermatology Physician
- License
- L2883
- Legal business name
- LADERA PARK DERMATOLOGY PA
- Practice address
- 11671 Jollyville Rd Ste 104
Austin, TX 78759-4141 - Phone
- (512) 345-3599
- Fax
- (512) 345-3928
- NPI assigned
- Jun 8, 2017
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Adrienne M Feasel, MD
- Title
- President
- Phone
- (512) 345-3599
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dermatology Physician | 207N00000X | L2883 | TX | Primary |
Addresses
Primary practice location
11671 Jollyville Rd Ste 104
Austin, TX 78759-4141
Mailing address
11671 Jollyville Rd Ste 104
Austin, TX 78759-4141
Phone (512) 345-3599
Other names 1
- Lake Travis Dermatology PA
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TX
Enrollment records 1
National Provider Directory
National Provider DirectoryPractitioners & affiliated clinicians
Practitioners 3
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Dermatology Physician
- Austin, TX
- NPI 1982664447
-
- Physician Assistant
- Austin, TX
- NPI 1134450497
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1496880000000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1658361600000",
"number": "1225567704",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11671 JOLLYVILLE RD STE 104",
"city": "AUSTIN",
"state": "TX",
"postal_code": "787594141",
"telephone_number": "512-345-3599",
"fax_number": "512-345-3928"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11671 JOLLYVILLE RD STE 104",
"city": "AUSTIN",
"state": "TX",
"postal_code": "787594141",
"telephone_number": "512-345-3599",
"fax_number": "512-345-3928"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "LADERA PARK DERMATOLOGY PA",
"organizational_subpart": "NO",
"enumeration_date": "2017-06-08",
"last_updated": "2022-07-21",
"status": "A",
"authorized_official_last_name": "FEASEL",
"authorized_official_first_name": "ADRIENNE",
"authorized_official_middle_name": "M",
"authorized_official_title_or_position": "PRESIDENT",
"authorized_official_telephone_number": "512-345-3599",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "207N00000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Dermatology",
"state": "TX",
"license": "L2883",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": [
{
"organization_name": "Lake Travis Dermatology PA",
"code": "4",
"type": "Former Legal Business Name"
}
]
}Other providers in Austin, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.