Healthcare Provider Details

I. General information

NPI: 1285694299
Provider Name (Legal Business Name): DIANE M SCOTT P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E MAIN ST SUITE D
PAYSON AZ
85541-5488
US

IV. Provider business mailing address

PO BOX 859
PAYSON AZ
85547-0859
US

V. Phone/Fax

Practice location:
  • Phone: 928-472-5260
  • Fax: 928-472-3444
Mailing address:
  • Phone: 928-472-5260
  • Fax: 928-472-3444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2192
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: