Provider Demographics
NPI:1265620991
Name:CEDAR PARK SURGEONS PA
Entity type:Organization
Organization Name:CEDAR PARK SURGEONS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BASA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-260-3444
Mailing Address - Street 1:1410 MEDICAL PKWY STE 1
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-2543
Mailing Address - Country:US
Mailing Address - Phone:512-260-3444
Mailing Address - Fax:512-260-3555
Practice Address - Street 1:1410 MEDICAL PKWY STE 1
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2543
Practice Address - Country:US
Practice Address - Phone:512-260-3444
Practice Address - Fax:512-260-3555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7029208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190188601Medicaid
TX0020QHOtherBCBS TX
TX0020QHOtherBCBS TX