Provider Demographics
NPI:1043864572
Name:SCOTT, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:FASHIMPAUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6952 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-1311
Mailing Address - Country:US
Mailing Address - Phone:630-621-5173
Mailing Address - Fax:
Practice Address - Street 1:TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
Practice Address - Street 2:3600 N GARFIELD
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705
Practice Address - Country:US
Practice Address - Phone:432-620-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA13911208M00000X, 363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program