Healthcare Provider Details

I. General information

NPI: 1114477072
Provider Name (Legal Business Name): EMPAC SURGICAL SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 10/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E VAN BUREN ST
PHOENIX AZ
85006-3742
US

IV. Provider business mailing address

271 E SPUR AVE
GILBERT AZ
85296-2239
US

V. Phone/Fax

Practice location:
  • Phone: 480-256-1518
  • Fax:
Mailing address:
  • Phone: 602-717-6779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2356
License Number StateAZ

VIII. Authorized Official

Name: MR. EMILE MANANSALA
Title or Position: PA-C
Credential: PA-C
Phone: 602-717-6779