Healthcare Provider Details

I. General information

NPI: 1003221052
Provider Name (Legal Business Name): GREG SCOTT REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2014
Last Update Date: 06/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N2722 TEN CROSSING RD
OGEMA WI
54459-8170
US

IV. Provider business mailing address

N2722 TEN CROSSING RD
OGEMA WI
54459-8170
US

V. Phone/Fax

Practice location:
  • Phone: 715-767-5250
  • Fax:
Mailing address:
  • Phone: 715-767-5250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number114407-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: