Provider Demographics
NPI:1356622583
Name:TRI-STATE SURGICAL ASSOCIATES
Entity type:Organization
Organization Name:TRI-STATE SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MEZA-VALENCIA
Authorized Official - Suffix:
Authorized Official - Credentials:C-SA
Authorized Official - Phone:571-244-4684
Mailing Address - Street 1:10332 MAIN ST # 344
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2410
Mailing Address - Country:US
Mailing Address - Phone:571-244-4684
Mailing Address - Fax:
Practice Address - Street 1:10332 MAIN ST # 344
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2410
Practice Address - Country:US
Practice Address - Phone:571-244-4684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2014-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty