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General NPI Number Information
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NPI Number | 1871143453
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL SURGICAL ASSISTANTS
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Dates
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Enumeration Date | 09/16/2019
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Last Update Date | 09/24/2019
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Provider Practice Location Address
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Address Line | 120 ACKLINS CIR APT 112
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City | DAYTONA BEACH
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State | FL
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Zip | 32119-9762
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Country | US
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Telephone | 708-269-0669
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Fax | 800-821-4719
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Provider Business Mailing Address
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Address Line | PO BOX 291613
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City | PORT ORANGE
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State | FL
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Zip | 32129-1613
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Country | US
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Telephone | 386-562-7052
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Fax | 800-821-4719
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Authorized Official
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Title or Position | OWNER
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Name | MS. CHRISTINA H REPKA
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Credential | RSA
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Telephone | 708-269-0669
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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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 |
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