Provider Demographics
NPI:1548342694
Name:MALE VAN RENSBURG, FELICIA
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:
Last Name:MALE VAN RENSBURG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FELICIA
Other - Middle Name:
Other - Last Name:MALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 N IH 35
Mailing Address - Street 2:SUITE 300
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-1926
Mailing Address - Country:US
Mailing Address - Phone:512-324-8300
Mailing Address - Fax:
Practice Address - Street 1:1400 N IH 35
Practice Address - Street 2:SUITE 300
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-1926
Practice Address - Country:US
Practice Address - Phone:512-324-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1010363A00000X
TXPA04980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX322866002Medicaid
TX347738YL9XMedicare PIN
TX347738YMGJMedicare PIN