Provider Demographics
NPI:1710160544
Name:ATHAIR, SCOT BACON (LPM)
Entity Type:Individual
Prefix:
First Name:SCOT
Middle Name:BACON
Last Name:ATHAIR
Suffix:
Gender:M
Credentials:LPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-4307
Mailing Address - Country:US
Mailing Address - Phone:360-452-3017
Mailing Address - Fax:
Practice Address - Street 1:1111 E FRONT ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-4307
Practice Address - Country:US
Practice Address - Phone:360-452-3017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-15
Last Update Date:2007-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00004385174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist