Basic Information
| Provider Information | |||||||||
| NPI: | 1770912313 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROZSYPAL | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1705 E 11TH ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787022709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129788400 | ||||||||
| FaxNumber: | 5129019726 | ||||||||
| Practice Location | |||||||||
| Address1: | 1705 E 11TH ST | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129788400 | ||||||||
| FaxNumber: | 5129019726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2013 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA9107501 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA9107501 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PA11896 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 010608200 | 05 | FL | MEDICAID | PA9107501 | 01 | FL | MEDICAL LICENSE | OTHER |