Provider Demographics
NPI:1528013364
Name:PRIME SURGICAL ASSISTING, LLC
Entity Type:Organization
Organization Name:PRIME SURGICAL ASSISTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:FULLMER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:480-216-2231
Mailing Address - Street 1:3760 E COTTON CT
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-4330
Mailing Address - Country:US
Mailing Address - Phone:480-216-2231
Mailing Address - Fax:
Practice Address - Street 1:2905 W WARNER RD STE 1
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-1674
Practice Address - Country:US
Practice Address - Phone:480-603-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZP-1257205-6363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty