Healthcare Provider Details

I. General information

NPI: 1831211317
Provider Name (Legal Business Name): TEXARKANA SURGICAL FIRST ASSISTANT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 SAINT MICHAEL DR
TEXARKANA TX
75503-2372
US

IV. Provider business mailing address

PO BOX 11219
FORT WORTH TX
76110-0219
US

V. Phone/Fax

Practice location:
  • Phone: 903-614-1000
  • Fax:
Mailing address:
  • Phone: 817-294-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberSA00281
License Number StateTX

VIII. Authorized Official

Name: MS. WENDY GORDON
Title or Position: LSA
Credential: LSA
Phone: 817-294-7444