Provider Demographics
NPI:1619243383
Name:SCOTT, MATTHEW A (PAC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:SCOTT
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 1:12479 TELECOM DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0913
Mailing Address - Country:US
Mailing Address - Phone:813-972-4199
Mailing Address - Fax:813-972-5753
Practice Address - Street 1:12479 TELECOM DR
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0913
Practice Address - Country:US
Practice Address - Phone:813-972-4199
Practice Address - Fax:813-972-5753
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106407363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAAAAAMedicare PIN