=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215570775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASA KRISTIAN SCOTT ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2019
-----------------------------------------------------
Last Update Date | 10/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2560 LAMBERT DR
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-616-2622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2560 LAMBERT DR
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91107-2618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-616-2622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207PS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Emergency Medicine) Physician
-----------------------------------------------------
License Number | J78467
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------