Provider Demographics
NPI:1871143453
Name:PROFESSIONAL SURGICAL ASSISTANTS
Entity type:Organization
Organization Name:PROFESSIONAL SURGICAL ASSISTANTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:H
Authorized Official - Last Name:REPKA
Authorized Official - Suffix:
Authorized Official - Credentials:RSA
Authorized Official - Phone:708-269-0669
Mailing Address - Street 1:PO BOX 291613
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-1613
Mailing Address - Country:US
Mailing Address - Phone:386-562-7052
Mailing Address - Fax:800-821-4719
Practice Address - Street 1:120 ACKLINS CIR APT 112
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-9762
Practice Address - Country:US
Practice Address - Phone:708-269-0669
Practice Address - Fax:800-821-4719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-16
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty