Provider Demographics
NPI:1144364795
Name:EMPRISE SURGICAL ASSOCIATE PLLC
Entity type:Organization
Organization Name:EMPRISE SURGICAL ASSOCIATE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MCREYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:480-860-1045
Mailing Address - Street 1:7846 E VISTA BONITA DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-4123
Mailing Address - Country:US
Mailing Address - Phone:480-860-1045
Mailing Address - Fax:480-664-8889
Practice Address - Street 1:7846 E VISTA BONITA DR
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-4123
Practice Address - Country:US
Practice Address - Phone:480-860-1045
Practice Address - Fax:480-664-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1480363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ881062Medicaid
AZR11743Medicare UPIN
AZ881062Medicaid