Provider Demographics
NPI:1942717301
Name:PREFERRED SURGICAL ASSOCIATES OF TEXAS
Entity Type:Organization
Organization Name:PREFERRED SURGICAL ASSOCIATES OF TEXAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:STATON
Authorized Official - Suffix:
Authorized Official - Credentials:LSA
Authorized Official - Phone:214-980-9437
Mailing Address - Street 1:PO BOX 938
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75030-0938
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:214-764-0880
Practice Address - Street 1:1208 PAINTBRUSH ST
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-2634
Practice Address - Country:US
Practice Address - Phone:214-227-2457
Practice Address - Fax:214-764-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1922530591Medicaid