Basic Information
| Provider Information | |||||||||
| NPI: | 1265031108 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARICOPA SURGICAL ASSIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 39179 | ||||||||
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| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850699179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023950718 | ||||||||
| FaxNumber: | 6022778146 | ||||||||
| Practice Location | |||||||||
| Address1: | 19829 N 27TH AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850274001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238796100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2020 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | CRAIG | ||||||||
| AuthorizedOfficialTitleorPosition: | SURGICAL FIRST ASSIST | ||||||||
| AuthorizedOfficialTelephone: | 6028823439 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CSA | ||||||||
| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.