Provider Demographics
NPI:1902205321
Name:PURE SURGICAL ASSISTANT
Entity Type:Organization
Organization Name:PURE SURGICAL ASSISTANT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:QIJUN
Authorized Official - Middle Name:
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:LSA, SA-C
Authorized Official - Phone:713-234-0081
Mailing Address - Street 1:PO BOX 79576
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77279-9576
Mailing Address - Country:US
Mailing Address - Phone:713-234-0081
Mailing Address - Fax:832-201-7900
Practice Address - Street 1:475 BENDWOOD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-8813
Practice Address - Country:US
Practice Address - Phone:281-409-3854
Practice Address - Fax:832-201-7900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-21
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00504363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty