=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134636632
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXPERT HANDS SURGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2018
-----------------------------------------------------
Last Update Date | 01/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29310 PRAIRIE ROSE CT
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-7384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-556-8819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29310 PRAIRIE ROSE CT
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77494-7384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SURGICAL ASSISTANT
-----------------------------------------------------
Name | NORBE LUIS BASULTO
-----------------------------------------------------
Credential | LSA
-----------------------------------------------------
Telephone | 786-556-8819
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | SA00474
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------