Provider Demographics
NPI:1053969287
Name:PREMIER PROCEDURAL DERMATOLOGY PLLC
Entity type:Organization
Organization Name:PREMIER PROCEDURAL DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:AHERN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-314-5400
Mailing Address - Street 1:1651 ROCK PRAIRIE RD STE 103
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-8652
Mailing Address - Country:US
Mailing Address - Phone:979-314-5400
Mailing Address - Fax:979-704-5603
Practice Address - Street 1:1651 ROCK PRAIRIE RD STE 103
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8652
Practice Address - Country:US
Practice Address - Phone:979-314-5400
Practice Address - Fax:979-704-5603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-30
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty