Basic Information
Provider Information
NPI: 1053854539
EntityType: 2
ReplacementNPI:  
OrganizationName: NORTHSIDE SURGICAL ASSISTANTS
LastName:  
FirstName:  
MiddleName:  
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NameSuffix:  
Credential:  
OtherOrganizationName:  
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Mailing Information
Address1: PO BOX 3346
Address2:  
City: SPRING
State: TX
PostalCode: 773833346
CountryCode: US
TelephoneNumber: 2142272457
FaxNumber: 2147640880
Practice Location
Address1: 24506 FORT PATH DR
Address2:  
City: SPRING
State: TX
PostalCode: 773737670
CountryCode: US
TelephoneNumber: 2142272457
FaxNumber: 2147640880
Other Information
ProviderEnumerationDate: 11/30/2016
LastUpdateDate: 01/25/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: AGUILAR
AuthorizedOfficialFirstName: ALEC
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 8326291380
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix: JR.
AuthorizedOfficialCredential: LSA
NPICertificationDate: 01/25/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
246ZC0007X4167TXN193400000X MULTIPLE SINGLE SPECIALTY GROUPTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherCertified First Assistant
246ZC0007X  Y193200000X MULTI-SPECIALTY GROUPTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherCertified First Assistant

No ID Information.


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