Healthcare Provider Details

I. General information

NPI: 1528533296
Provider Name (Legal Business Name): SCOTT CORY STUART PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 02/20/2020
Certification Date: 02/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1344 HILAND AVE STE D
BURLEY ID
83318-1564
US

IV. Provider business mailing address

147 W CHUBBUCK RD
CHUBBUCK ID
83202-2314
US

V. Phone/Fax

Practice location:
  • Phone: 208-572-6005
  • Fax: 208-261-3066
Mailing address:
  • Phone: 208-238-7546
  • Fax: 208-237-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1850
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: