Provider Demographics
NPI:1174868095
Name:SCOTT, NATHAN WADE (APRN)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:WADE
Last Name:SCOTT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:154 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2373
Practice Address - Country:US
Practice Address - Phone:860-395-1212
Practice Address - Fax:860-358-8654
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily