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General NPI Number Information
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NPI Number | 1487027504
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Entity Type | Organization
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Legal Business Name | ADVANCED SURGICAL ASSISTANTS LLC
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Dates
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Enumeration Date | 11/11/2015
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Last Update Date | 11/11/2015
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Provider Practice Location Address
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Address Line | 1924 30TH AVE STE A
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City | GULFPORT
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State | MS
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Zip | 39501-4534
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Country | US
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Telephone | 228-206-7634
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Fax | 228-206-4523
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Provider Business Mailing Address
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Address Line | 1924 30TH AVE STE A
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City | GULFPORT
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State | MS
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Zip | 39501-4534
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Country | US
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Telephone | 228-206-7634
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Fax | 228-206-4523
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Authorized Official
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Title or Position | SURGICAL FIRST ASSISTANT
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Name | MR. ROBERT LEE GILLUM JR.
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Credential | SFA
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Telephone | 228-343-3044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number |
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License Number State | MS
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