Provider Demographics
NPI:1205852969
Name:HEARN, SCOTT (PAC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:HEARN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5896 ROSIE LN SE
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-2725
Mailing Address - Country:US
Mailing Address - Phone:770-941-7716
Mailing Address - Fax:727-507-3618
Practice Address - Street 1:3949 S COBB DR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-6342
Practice Address - Country:US
Practice Address - Phone:770-438-5222
Practice Address - Fax:770-434-5123
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P89621Medicare UPIN