=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700907664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINGWOOD SURGICAL ASSISTANTS OF TEXAS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2007
-----------------------------------------------------
Last Update Date | 10/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3019 HONEYGUIDE CT
-----------------------------------------------------
City | PORTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77365-2289
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-357-9287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5798
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77325-5798
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DEBRA DECATO
-----------------------------------------------------
Credential | LSA
-----------------------------------------------------
Telephone | 713-357-9287
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------