MEDICARE: FIRST PEAK SURGICAL ASSISTING

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	PA9103288	FL

General Provider Information

NPI Number	:	1982113916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST PEAK SURGICAL ASSISTING

Provider Business Mailing Address
First Line	:	310 AMBERJACK PL
Second Line	:
City	:	MELBOURNE BEACH
State	:	FL
Zip	:	32951-2906
Country	:	US
Telephone Number	:	321-684-1193
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 AMBERJACK PL
Second Line	:
City	:	MELBOURNE BEACH
State	:	FL
Zip	:	32951-2906
Country	:	US
Telephone Number	:	321-684-1193
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAMES DANIEL MOORE
Credential	:
Telephone Number	:	321-684-1193

Provider Enumeration Date	:	09/21/2017
Last Update Date	:	07/21/2022

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