MEDICARE: ELITE SURGICAL ASSISTING, 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	363AS0400X	Surgical Physician Assistant

General Provider Information

NPI Number	:	1265920565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE SURGICAL ASSISTING, LLC

Provider Business Mailing Address
First Line	:	2924 S 98TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129-4407
Country	:	US
Telephone Number	:	918-361-7366
Fax Number	:

Provider Business Practice Location Address
First Line	:	2924 S 98TH EAST AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74129-4407
Country	:	US
Telephone Number	:	918-361-7366
Fax Number	:

Authorized Official
Title or Position	:	CERTIFIED SURGICAL FIRST ASSISTANT
Name	:	BROOKE JAVON DENTON
Credential	:	CSFA
Telephone Number	:	918-361-7366

Provider Enumeration Date	:	04/23/2018
Last Update Date	:	04/23/2018

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