Provider Demographics
NPI:1992092951
Name:AGELESS ABANDON
Entity type:Organization
Organization Name:AGELESS ABANDON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GANSKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-459-4400
Mailing Address - Street 1:1010 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-4924
Mailing Address - Country:US
Mailing Address - Phone:512-459-4400
Mailing Address - Fax:
Practice Address - Street 1:103 TAMARAC CT
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4666
Practice Address - Country:US
Practice Address - Phone:512-459-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5718207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty