=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144364795
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMPRISE SURGICAL ASSOCIATE PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2007
-----------------------------------------------------
Last Update Date | 03/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7846 E VISTA BONITA DR
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-860-1045
-----------------------------------------------------
Fax | 480-664-8889
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7846 E VISTA BONITA DR
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85255-4123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-860-1045
-----------------------------------------------------
Fax | 480-664-8889
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | SAMUEL DAVID MCREYNOLDS
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 480-860-1045
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 1480
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------