Basic Information
| Provider Information | |||||||||
| NPI: | 1790430072 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 360 SURGICAL ASSISTING OF CENTRAL TEXAS,LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2950 E OLD SETTLERS BLVD UNIT 30 | ||||||||
| Address2: | |||||||||
| City: | ROUND ROCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786652478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5126441931 | ||||||||
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| Practice Location | |||||||||
| Address1: | 901 W BEN WHITE BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787046903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5124472211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2022 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | BOLANOS | ||||||||
| AuthorizedOfficialFirstName: | HERIBERTO | ||||||||
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| AuthorizedOfficialTitleorPosition: | CERTIFIED SURGICAL FIRST ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 5126441931 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.