Healthcare Provider Details

I. General information

NPI: 1134210768
Provider Name (Legal Business Name): SCOTT THOMAS WILEY P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 S RIDGEVIEW DR STE 201
YUMA AZ
85364-8880
US

IV. Provider business mailing address

2400 S AVENUE A
YUMA AZ
85364-7127
US

V. Phone/Fax

Practice location:
  • Phone: 928-344-5055
  • Fax:
Mailing address:
  • Phone: 928-344-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2144
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: