=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558990903
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANSURIO EXCEED ASSOCIATES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2020
-----------------------------------------------------
Last Update Date | 04/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11800 HORSESHOE RIDGE DR
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76244-4892
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-208-6286
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 77934
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76177-0934
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-208-6286
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | ANSURIO CARDONA JR.
-----------------------------------------------------
Credential | LSA
-----------------------------------------------------
Telephone | 214-208-6286
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------