Healthcare Provider Details

I. General information

NPI: 1194947325
Provider Name (Legal Business Name): SCOTT L. DACK MPAS/ATC/PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 30TH AVE W
ALEXANDRIA MN
56308-3426
US

IV. Provider business mailing address

610 30TH AVE W
ALEXANDRIA MN
56308-3426
US

V. Phone/Fax

Practice location:
  • Phone: 320-763-2540
  • Fax: 320-763-2540
Mailing address:
  • Phone: 320-763-5123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10290
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: