Healthcare Provider Details

I. General information

NPI: 1801413174
Provider Name (Legal Business Name): PA-C SURGICAL ASSIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 TROTTERS RUN
MACON GA
31210-8653
US

IV. Provider business mailing address

PO BOX 26096
MACON GA
31221-6096
US

V. Phone/Fax

Practice location:
  • Phone: 858-337-0498
  • Fax: 478-750-7756
Mailing address:
  • Phone: 858-337-0498
  • Fax: 478-750-7756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY GIBBERT
Title or Position: OWNER
Credential: PA
Phone: 858-337-0498