Healthcare Provider Details

I. General information

NPI: 1265031108
Provider Name (Legal Business Name): MARICOPA SURGICAL ASSIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2020
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19829 N 27TH AVE
PHOENIX AZ
85027-4001
US

IV. Provider business mailing address

PO BOX 39179
PHOENIX AZ
85069-9179
US

V. Phone/Fax

Practice location:
  • Phone: 623-879-6100
  • Fax:
Mailing address:
  • Phone: 602-395-0718
  • Fax: 602-277-8146

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MATTHEW CRAIG LEWIS
Title or Position: SURGICAL FIRST ASSIST
Credential: CSA
Phone: 602-882-3439