Provider Demographics
NPI:1619590791
Name:EXCELSA SURGICAL ASSISTANT LLC
Entity Type:Organization
Organization Name:EXCELSA SURGICAL ASSISTANT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVARES-ALVARADO
Authorized Official - Suffix:
Authorized Official - Credentials:LSA
Authorized Official - Phone:281-827-6521
Mailing Address - Street 1:PO BOX 751763
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77275-1763
Mailing Address - Country:US
Mailing Address - Phone:281-827-6521
Mailing Address - Fax:
Practice Address - Street 1:1826 PLEASANT SPRINGS LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-1498
Practice Address - Country:US
Practice Address - Phone:281-827-6521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-22
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty