1114007028 NPI number — MICHAEL D SCOTT PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114007028 NPI number — MICHAEL D SCOTT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SCOTT
Provider First Name:
MICHAEL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114007028
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4136B LARAMIE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHEYENNE
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82001-1969
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-637-2800
Provider Business Mailing Address Fax Number:
307-637-2867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4017 RAWLINS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHEYENNE
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82001-1800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-635-2562
Provider Business Practice Location Address Fax Number:
307-637-2867
Provider Enumeration Date:
10/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA208 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA-2238 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 208 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 970026026 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 111303800 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 311196 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".