Healthcare Provider Details

I. General information

NPI: 1659795359
Provider Name (Legal Business Name): PBP SURGICAL ASSIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2014
Last Update Date: 02/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12335 KINGSRIDE LN STE 275
HOUSTON TX
77024-4116
US

IV. Provider business mailing address

12335 KINGSRIDE LN STE 275
HOUSTON TX
77024-4116
US

V. Phone/Fax

Practice location:
  • Phone: 713-464-0077
  • Fax: 713-464-9582
Mailing address:
  • Phone: 713-464-0077
  • Fax: 713-464-9582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. JUAN BUSTOS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 713-464-0077