Provider Demographics
NPI:1497897748
Name:ANDERSON, SCOTT EDWARD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:EDWARD
Last Name:ANDERSON
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 1:1719 S CANOE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-7755
Mailing Address - Country:US
Mailing Address - Phone:719-210-5051
Mailing Address - Fax:
Practice Address - Street 1:DIRAIMONDO TROOP MEDICAL CLINIC #9
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:719-210-5051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant