=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619492642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY AREA SURGICAL ASSISTING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2017
-----------------------------------------------------
Last Update Date | 12/16/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4122 MADISON ST UNIT 262
-----------------------------------------------------
City | ELFERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34680-9711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-310-5679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4122 MADISON ST UNIT 262
-----------------------------------------------------
City | ELFERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34680-9711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-310-5679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. LEONARD PAUL JOHNS
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 813-310-5679
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA9102691
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------