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NPI Code Detail

MEDICARE: PEORIA SURGERY ASSIST, PLLC

MEDICARE: PEORIA SURGERY ASSIST, PLLC
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
1363A00000XPhysician Assistant

General Provider Information

NPI Number : 1386266427
Entity Type Code : Organization
Provider Name (Legal Business Name) : PEORIA SURGERY ASSIST, PLLC
Provider Business Mailing Address
First Line : 1141 N LOOP 1604 E #105-612
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78232
Country : US
Telephone Number : 210-598-4262
Fax Number :
Provider Business Practice Location Address
First Line : 16165 N 83RD AVE STE 200
Second Line :
City : PEORIA
State : AZ
Zip : 85382-5816
Country : US
Telephone Number : 210-598-4262
Fax Number :
Authorized Official
Title or Position : DIRECTOR OF CLIENT EXPERIENCE
Name : ROXANNA LAROQUE
Credential :
Telephone Number : 210-598-4262
Provider Enumeration Date : 05/12/2020
Last Update Date : 09/22/2022

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Directions to “PEORIA SURGERY ASSIST, PLLC ” Practice Location

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