Provider Demographics
NPI:1619233582
Name:CAPITAL ADVANCED SURGERY A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CAPITAL ADVANCED SURGERY A PROFESSIONAL CORPORATION
Other - Org Name:CAPITAL ADVANCED SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-455-8666
Mailing Address - Street 1:3511 DEL PASO ROAD
Mailing Address - Street 2:SUITE 160 PMB 226
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-2808
Mailing Address - Country:US
Mailing Address - Phone:916-455-8666
Mailing Address - Fax:916-455-8866
Practice Address - Street 1:8100 BRUCEVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2353
Practice Address - Country:US
Practice Address - Phone:916-714-6666
Practice Address - Fax:916-714-6677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA113444208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty