Provider Demographics
NPI:1376901843
Name:PHENOMSURGICAL ASSISTING
Entity Type:Organization
Organization Name:PHENOMSURGICAL ASSISTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:LSA
Authorized Official - Phone:510-984-8610
Mailing Address - Street 1:4026 E TEAL ESTATES CIR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-8851
Mailing Address - Country:US
Mailing Address - Phone:510-984-8610
Mailing Address - Fax:
Practice Address - Street 1:4026 E TEAL ESTATES CIR
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-8851
Practice Address - Country:US
Practice Address - Phone:510-984-8610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-29
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00547246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty