Provider Demographics
NPI:1235497561
Name:SHORE SURGICAL ASSISTING LLC
Entity Type:Organization
Organization Name:SHORE SURGICAL ASSISTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOOSACK
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:732-236-1104
Mailing Address - Street 1:1070 CLEARWATER AVE
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2303
Mailing Address - Country:US
Mailing Address - Phone:732-236-1104
Mailing Address - Fax:609-978-2750
Practice Address - Street 1:1070 CLEARWATER AVE
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2303
Practice Address - Country:US
Practice Address - Phone:732-236-1104
Practice Address - Fax:609-978-2750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00132300363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MP00132300OtherPHYSICIAN ASSISTANT LICENSE
NJA00006300OtherCDS
NJA00006300OtherCDS
MH1342295OtherDEA