Provider Demographics
NPI:1881290104
Name:EAST SIDE SURGICAL LLC
Entity type:Organization
Organization Name:EAST SIDE SURGICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LE-MAHON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:408-202-5064
Mailing Address - Street 1:3474 NOBLE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-3132
Mailing Address - Country:US
Mailing Address - Phone:408-857-9231
Mailing Address - Fax:
Practice Address - Street 1:815 POLLARD RD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1438
Practice Address - Country:US
Practice Address - Phone:408-378-6131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-10
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty