MEDICARE: ILIA AYUB LSA

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	246ZC0007X	Surgical Assistant	SA00329	TX
2	246ZS0410X	Surgical Technologist	SA00329	TX
3	246ZS0410X	Surgical Technologist	2947	TX
4	363LF0000X	Family Nurse Practitioner	1012927	TX

General Provider Information

NPI Number	:	1568580058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILIA AYUB LSA

Provider Business Mailing Address
First Line	:	14947 CAMINO RANCHO DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-3222
Country	:	US
Telephone Number	:	713-823-0197
Fax Number	:	713-823-0197

Provider Business Practice Location Address
First Line	:	14947 CAMINO RANCHO DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-3222
Country	:	US
Telephone Number	:	713-823-0197
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	04/23/2024

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