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General NPI Number Information
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NPI Number | 1376901843
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Entity Type | Organization
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Legal Business Name | PHENOMSURGICAL ASSISTING
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Dates
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Enumeration Date | 01/29/2016
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Last Update Date | 04/04/2016
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Provider Practice Location Address
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Address Line | 4026 E TEAL ESTATES CIR
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City | FRESNO
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State | TX
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Zip | 77545-8851
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Country | US
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Telephone | 510-984-8610
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Fax |
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Provider Business Mailing Address
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Address Line | 4026 E TEAL ESTATES CIR
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City | FRESNO
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State | TX
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Zip | 77545-8851
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Country | US
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Telephone | 510-984-8610
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GWENDOLYN CHAMPION
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Credential | LSA
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Telephone | 510-984-8610
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZC0007X
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Taxonomy Name | Surgical Assistant
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License Number | SA00547
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License Number State | TX
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