Provider Demographics
NPI:1801413174
Name:PA-C SURGICAL ASSIST, LLC
Entity Type:Organization
Organization Name:PA-C SURGICAL ASSIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBERT
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:404-907-3292
Mailing Address - Street 1:PO BOX 1706
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30031-1706
Mailing Address - Country:US
Mailing Address - Phone:404-907-3292
Mailing Address - Fax:
Practice Address - Street 1:520 W PONCE LEON AVE #1706
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030
Practice Address - Country:US
Practice Address - Phone:404-907-3292
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical