MEDICARE: EXCELSA SURGICAL ASSISTANT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1619590791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCELSA SURGICAL ASSISTANT LLC

Provider Business Mailing Address
First Line	:	PO BOX 751763
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77275-1763
Country	:	US
Telephone Number	:	281-827-6521
Fax Number	:

Provider Business Practice Location Address
First Line	:	1826 PLEASANT SPRINGS LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77089-1498
Country	:	US
Telephone Number	:	281-827-6521
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JACQUELINE TAVARES-ALVARADO
Credential	:	LSA
Telephone Number	:	281-827-6521

Provider Enumeration Date	:	05/22/2020
Last Update Date	:	06/11/2020

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