Healthcare Provider Details

I. General information

NPI: 1558389841
Provider Name (Legal Business Name): GARY ALLEN SCOTT FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 SUNSET DR SUITE D
LOS OSOS CA
93402-4007
US

IV. Provider business mailing address

2605 GREENWOOD AVE
MORRO BAY CA
93442-1546
US

V. Phone/Fax

Practice location:
  • Phone: 805-528-0650
  • Fax: 805-528-1690
Mailing address:
  • Phone: 805-772-1506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN 320903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: