Healthcare Provider Details

I. General information

NPI: 1215113022
Provider Name (Legal Business Name): JACOB D SKORUPPA LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 03/12/2023
Certification Date: 03/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5929 BRIGHTWOOD DR
CORPUS CHRISTI TX
78414-3029
US

IV. Provider business mailing address

5929 BRIGHTWOOD DR
CORPUS CHRISTI TX
78414-3029
US

V. Phone/Fax

Practice location:
  • Phone: 361-876-6689
  • Fax: 361-336-0217
Mailing address:
  • Phone: 361-876-6689
  • Fax: 361-336-0217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberSA00374
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberSA00374
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: