Healthcare Provider Details

I. General information

NPI: 1447787882
Provider Name (Legal Business Name): SCOTT EDWARD EWING FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 04/30/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1648 HIGHWAY 95
BULLHEAD CITY AZ
86442-7906
US

IV. Provider business mailing address

1648 HIGHWAY 95
BULLHEAD CITY AZ
86442-7906
US

V. Phone/Fax

Practice location:
  • Phone: 928-758-4114
  • Fax: 928-758-4650
Mailing address:
  • Phone: 928-758-4114
  • Fax: 928-758-4650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10115
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAP10115
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: