Provider Demographics
NPI:1942579750
Name:PHYSICIAN ASSISTANT - SURGICAL ASSIST, LLC
Entity Type:Organization
Organization Name:PHYSICIAN ASSISTANT - SURGICAL ASSIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:VINCELETTE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:480-215-3035
Mailing Address - Street 1:4980 S ALMA SCHOOL RD
Mailing Address - Street 2:A2-130
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-5545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4980 S ALMA SCHOOL RD
Practice Address - Street 2:A2-130
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-5545
Practice Address - Country:US
Practice Address - Phone:480-215-3035
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2841363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty