Healthcare Provider Details

I. General information

NPI: 1457714388
Provider Name (Legal Business Name): CERTIFIED SURGICAL FIRST ASSISTANT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2016
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 E RIGGS RD STE 8-166
CHANDLER AZ
85249-3600
US

IV. Provider business mailing address

2925 E RIGGS RD STE 8-166
CHANDLER AZ
85249-3600
US

V. Phone/Fax

Practice location:
  • Phone: 480-545-2610
  • Fax: 480-545-2673
Mailing address:
  • Phone: 602-909-4623
  • Fax: 480-545-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name: KATHLEEN E BAGWELL
Title or Position: GENERAL MANAGER
Credential:
Phone: 480-545-2610