Provider Demographics
NPI:1023563749
Name:NCG SURGICAL SERVICES
Entity Type:Organization
Organization Name:NCG SURGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSSIS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:925-330-6666
Mailing Address - Street 1:1004 SADDLEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-3829
Mailing Address - Country:US
Mailing Address - Phone:925-330-6666
Mailing Address - Fax:
Practice Address - Street 1:1004 SADDLEBROOK DR
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-3829
Practice Address - Country:US
Practice Address - Phone:925-330-6666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05759363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty