Provider Demographics
NPI:1326228552
Name:ETHRIDGE, SCOTT DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:DAVID
Last Name:ETHRIDGE
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 1:4619 KANAWHA AVE SW
Mailing Address - Street 2:SUITE 806
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1319
Mailing Address - Country:US
Mailing Address - Phone:304-400-4545
Mailing Address - Fax:304-400-4546
Practice Address - Street 1:3100 MACCORKLE AVE SE
Practice Address - Street 2:SUITE 806
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1223
Practice Address - Country:US
Practice Address - Phone:304-344-9480
Practice Address - Fax:304-344-9481
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01317363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVETPA29972Medicare PIN
WVETPA29971Medicare PIN