Healthcare Provider Details

I. General information

NPI: 1316361553
Provider Name (Legal Business Name): CUTTING EDGE SURGICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 02/07/2014
Certification Date:
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:
Mailing address:
  • Phone: 361-876-6689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number00374
License Number StateTX

VIII. Authorized Official

Name: JACOB D SKORUPPA
Title or Position: CEO
Credential: LSA
Phone: 361-876-6689