Healthcare Provider Details

I. General information

NPI: 1215570775
Provider Name (Legal Business Name): ASA KRISTIAN SCOTT ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2560 LAMBERT DR
PASADENA CA
91107-2618
US

IV. Provider business mailing address

2560 LAMBERT DR
PASADENA CA
91107-2618
US

V. Phone/Fax

Practice location:
  • Phone: 626-616-2622
  • Fax:
Mailing address:
  • Phone: 626-616-2622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberJ78467
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: