Provider Demographics
NPI:1962824896
Name:PLATINUM SURGICAL ASSISTANTS
Entity Type:Organization
Organization Name:PLATINUM SURGICAL ASSISTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:NOLLIE
Authorized Official - Suffix:
Authorized Official - Credentials:CSA/LPN
Authorized Official - Phone:301-363-4934
Mailing Address - Street 1:3570 OLNEY LAYTONSVILLE RD UNIT 71
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20830-7503
Mailing Address - Country:US
Mailing Address - Phone:301-363-4934
Mailing Address - Fax:301-363-4934
Practice Address - Street 1:8115 MAPLE LAWN BLVD STE 350
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MD
Practice Address - Zip Code:20759-2683
Practice Address - Country:US
Practice Address - Phone:301-363-4934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-12
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP49426164W00000X
MD3077246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty