Healthcare Provider Details

I. General information

NPI: 1942354766
Provider Name (Legal Business Name): SCOTT A. SUTPHIN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 SHENANDOAH AVE NW
ROANOKE VA
24017-4749
US

IV. Provider business mailing address

4550 SHENANDOAH AVE NW
ROANOKE VA
24017-4749
US

V. Phone/Fax

Practice location:
  • Phone: 540-982-2860
  • Fax:
Mailing address:
  • Phone: 540-982-2860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306602211
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: