Healthcare Provider Details

I. General information

NPI: 1396105904
Provider Name (Legal Business Name): ABSOLUTE SURGICAL ASSISTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4653 POND LN
MARIETTA GA
30062-5618
US

IV. Provider business mailing address

4653 POND LN
MARIETTA GA
30062-5618
US

V. Phone/Fax

Practice location:
  • Phone: 770-330-5549
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN195446
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE LARUE
Title or Position: CEO
Credential:
Phone: 770-330-5549