MEDICARE: PROASSIST SURGICAL ASSOCIATES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZS0410X	Surgical Technologist	CERT 82396	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	412217629	OTHER	TX	OLD TAX ID
2	613033500	OTHER	TX	DOL
3	0062PC	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1083788848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROASSIST SURGICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	2150 S CENTRAL EXPY
Second Line	:	STE 130
City	:	MCKINNEY
State	:	TX
Zip	:	75070-4070
Country	:	US
Telephone Number	:	972-363-8200
Fax Number	:	972-363-8196

Provider Business Practice Location Address
First Line	:	2150 S CENTRAL EXPY
Second Line	:	STE 130
City	:	MCKINNEY
State	:	TX
Zip	:	75070-4070
Country	:	US
Telephone Number	:	972-363-8200
Fax Number	:	972-363-8196

Authorized Official
Title or Position	:	PARTNER
Name	:	MICHAEL W FULLER
Credential	:	PA-C
Telephone Number	:	972-363-8200

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	02/10/2011

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