Healthcare Provider Details

I. General information

NPI: 1619544178
Provider Name (Legal Business Name): SURGICAL PHYSICIAN ASSISTANT SPECIALIST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2021
Last Update Date: 01/01/2026
Certification Date: 01/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

1401 21ST ST STE R
SACRAMENTO CA
95811-5226
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: ZACHARY PERIHAROS
Title or Position: OWNER
Credential:
Phone: 978-822-6348