MEDICARE: CHARLOTTE SCOTT PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA01636	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00269379	OTHER	TX	RR/MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	8N9121	OTHER	TX	BLUE SHIELD

General Provider Information

NPI Number	:	1063475309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE SCOTT PA

Provider Business Mailing Address
First Line	:	4204 E STAN SCHLUETER LOOP
Second Line	:
City	:	KILLEEN
State	:	TX
Zip	:	76542-8352
Country	:	US
Telephone Number	:	254-690-2800
Fax Number	:	254-690-5401

Provider Business Practice Location Address
First Line	:	BLDG 2245, 58TH STREET AND 761ST TANK BATTALION AVENUE
Second Line	:
City	:	FORT HOOD
State	:	TX
Zip	:	76544-0000
Country	:	US
Telephone Number	:	254-287-5029
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2006
Last Update Date	:	10/20/2015

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Directions to “ CHARLOTTE SCOTT PA” Practice Location

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