Healthcare Provider Details

I. General information

NPI: 1790279321
Provider Name (Legal Business Name): STEPHANIE ANNE SCOTT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 04/12/2021
Certification Date: 04/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5904 HOLLY AVE NE
ALBUQUERQUE NM
87113-2472
US

IV. Provider business mailing address

9500 OSUNA RD NE APT 318
ALBUQUERQUE NM
87111-2283
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-2505
  • Fax:
Mailing address:
  • Phone: 505-220-0427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2018-0035
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: