Provider Demographics
NPI:1578651717
Name:WILSON-SCOTT, KARASA A (AUD)
Entity Type:Individual
Prefix:
First Name:KARASA
Middle Name:A
Last Name:WILSON-SCOTT
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8310
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-0310
Mailing Address - Country:US
Mailing Address - Phone:540-345-3556
Mailing Address - Fax:540-342-2193
Practice Address - Street 1:5875 BREMO RD
Practice Address - Street 2:STE 212
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1934
Practice Address - Country:US
Practice Address - Phone:804-504-0530
Practice Address - Fax:804-504-0532
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001214231H00000X
VA2101001461237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAMC11335OtherMEDICARE INDIVIDUAL PTAN
VA362423OtherANTHEM
VA1578651717Medicaid