Healthcare Provider Details

I. General information

NPI: 1770295057
Provider Name (Legal Business Name): EAST VALLEY SURGICAL ASSISTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2022
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8540 E MCDOWELL RD UNIT 38
MESA AZ
85207-1419
US

IV. Provider business mailing address

5155 E. EAGLE DRIVE # 20730
MESA AZ
85277-3031
US

V. Phone/Fax

Practice location:
  • Phone: 480-706-9430
  • Fax: 480-378-2273
Mailing address:
  • Phone: 480-706-9430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1407005549
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer
# 2
Identifier1407005549
Identifier TypeOTHER
Identifier StateAZ
Identifier IssuerVA, PRIVATE INSURERS, BUREAU OF INDIAN AFFAIRS

VIII. Authorized Official

Name: MR. CHARLES LAURENT LEVESQUE
Title or Position: OWNER
Credential: PA-C
Phone: 480-296-9893