Basic Information
| Provider Information | |||||||||
| NPI: | 1235669268 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN ASSISTANT SURGASSIST, INC. | ||||||||
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| OtherOrganizationName: | SURGASSIST, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 SANTA CORA AVE APT 627 | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919131555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512062347 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5555 GROSSMONT CENTER DR | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197406000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 06/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | ANAK-AGUNG-GEDE | ||||||||
| AuthorizedOfficialFirstName: | ANGEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9512062347 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.