Provider Demographics
NPI:1780735027
Name:ACEBO, BYSMARK A (LSA)
Entity type:Individual
Prefix:MR
First Name:BYSMARK
Middle Name:A
Last Name:ACEBO
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20023 SKY HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-5219
Mailing Address - Country:US
Mailing Address - Phone:832-713-9153
Mailing Address - Fax:
Practice Address - Street 1:20023 SKY HOLLOW LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-5219
Practice Address - Country:US
Practice Address - Phone:832-713-9153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00008246ZC0007X
TXSA 0008363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant