Healthcare Provider Details

I. General information

NPI: 1235669268
Provider Name (Legal Business Name): PHYSICIAN ASSISTANT SURGASSIST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

1250 SANTA CORA AVE APT 627
CHULA VISTA CA
91913-1555
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-6000
  • Fax:
Mailing address:
  • Phone: 951-206-2347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGEL ANAK-AGUNG-GEDE
Title or Position: PRESIDENT
Credential: PA-C
Phone: 951-206-2347