Provider Demographics
NPI:1619544178
Name:SURGICAL PHYSICIAN ASSISTANT SPECIALIST, INC.
Entity Type:Organization
Organization Name:SURGICAL PHYSICIAN ASSISTANT SPECIALIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PERIHAROS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:978-822-6348
Mailing Address - Street 1:1640 10TH AVE UNIT 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2873
Mailing Address - Country:US
Mailing Address - Phone:978-822-6348
Mailing Address - Fax:
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-740-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization