Provider Demographics
NPI:1225677149
Name:FETTERS, JULIA NICOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JULIA
Middle Name:NICOLE
Last Name:FETTERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:NICOLE
Other - Last Name:BACAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10625 W PARMER LN STE D400
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-4016
Mailing Address - Country:US
Mailing Address - Phone:512-733-9400
Mailing Address - Fax:
Practice Address - Street 1:10625 W PARMER LN STE D400
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-4016
Practice Address - Country:US
Practice Address - Phone:512-733-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
TXPA13442363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA13442OtherTEXAS MEDICAL BOARD