Provider Demographics
NPI:1689603813
Name:WITHERS, SCOTT K (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:K
Last Name:WITHERS
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 1:246 CAMP RD
Mailing Address - Street 2:
Mailing Address - City:COOPER
Mailing Address - State:ME
Mailing Address - Zip Code:04657
Mailing Address - Country:US
Mailing Address - Phone:207-454-7693
Mailing Address - Fax:207-454-0929
Practice Address - Street 1:246 CAMP RD
Practice Address - Street 2:
Practice Address - City:COOPER
Practice Address - State:ME
Practice Address - Zip Code:04657-3221
Practice Address - Country:US
Practice Address - Phone:207-454-7693
Practice Address - Fax:207-454-0929
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA193363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MES2017Medicaid