Provider Demographics
NPI:1073701322
Name:ISHMAEL, SCOTT KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:KEVIN
Last Name:ISHMAEL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 BROADSTONE PKWY
Mailing Address - Street 2:APPT 3622
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-8478
Mailing Address - Country:US
Mailing Address - Phone:530-409-5755
Mailing Address - Fax:
Practice Address - Street 1:1350 BROADSTONE PKWY
Practice Address - Street 2:APPT 3622
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-8478
Practice Address - Country:US
Practice Address - Phone:530-409-5755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18592363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical