Healthcare Provider Details

I. General information

NPI: 1356535322
Provider Name (Legal Business Name): SCOTT MATHIS APRN,BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2007
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 ALICE ST
WAYCROSS GA
31501-4525
US

IV. Provider business mailing address

120 E CARTER AVE
BLACKSHEAR GA
31516-1561
US

V. Phone/Fax

Practice location:
  • Phone: 912-284-9800
  • Fax: 912-284-1711
Mailing address:
  • Phone: 912-449-1501
  • Fax: 912-449-1517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN00138004
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: