Provider Demographics
NPI:1316056260
Name:ST. VRAIN SURGICAL ASSISTS, LLC
Entity type:Organization
Organization Name:ST. VRAIN SURGICAL ASSISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MGR
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:PA/C
Authorized Official - Phone:303-819-2025
Mailing Address - Street 1:77 BAYLOR DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-2148
Mailing Address - Country:US
Mailing Address - Phone:303-819-2025
Mailing Address - Fax:720-494-0995
Practice Address - Street 1:77 BAYLOR DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-2148
Practice Address - Country:US
Practice Address - Phone:303-819-2025
Practice Address - Fax:720-494-0995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO519363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC801455Medicare PIN