Provider Demographics
NPI:1114007028
Name:SCOTT, MICHAEL D (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:SCOTT
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 1:4136B LARAMIE STREET
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1969
Mailing Address - Country:US
Mailing Address - Phone:307-637-2800
Mailing Address - Fax:307-637-2867
Practice Address - Street 1:4017 RAWLINS ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1800
Practice Address - Country:US
Practice Address - Phone:307-635-2562
Practice Address - Fax:307-637-2867
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPA208363A00000X
COPA-2238363AS0400X
WY208363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY970026026OtherRAIL ROAD MEDICARE
WY111303800Medicaid
WY311196OtherBLUE CROSS BLUE SHIELD
WY311196OtherBLUE CROSS BLUE SHIELD
WYW21423Medicare PIN