Provider Demographics
NPI:1679122907
Name:POPPELL, SCOT JOSEPH
Entity Type:Individual
Prefix:MR
First Name:SCOT
Middle Name:JOSEPH
Last Name:POPPELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4392 FOREST EDGE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-9670
Mailing Address - Country:US
Mailing Address - Phone:850-849-1971
Mailing Address - Fax:
Practice Address - Street 1:1670 ST VINCENTS WAY
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8447
Practice Address - Country:US
Practice Address - Phone:904-602-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9112464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant