Provider Demographics
NPI:1194017954
Name:DIRECT SURGICAL ASSIST PA
Entity Type:Organization
Organization Name:DIRECT SURGICAL ASSIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-989-0598
Mailing Address - Street 1:695 N ASPEN LAKES WAY
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-5674
Mailing Address - Country:US
Mailing Address - Phone:208-989-0598
Mailing Address - Fax:
Practice Address - Street 1:695 N ASPEN LAKES WAY
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-5674
Practice Address - Country:US
Practice Address - Phone:208-989-0598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty