Provider Demographics
NPI:1952590077
Name:FALL CREEK SURGICAL ASSISTANTS
Entity Type:Organization
Organization Name:FALL CREEK SURGICAL ASSISTANTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCCLEERY
Authorized Official - Suffix:
Authorized Official - Credentials:LSA
Authorized Official - Phone:817-605-0991
Mailing Address - Street 1:PO BOX 820428
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76182-0428
Mailing Address - Country:US
Mailing Address - Phone:817-605-0991
Mailing Address - Fax:817-605-0993
Practice Address - Street 1:1504 KELSEY DR
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-6878
Practice Address - Country:US
Practice Address - Phone:817-605-0991
Practice Address - Fax:817-605-0993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00132363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty