Provider Demographics
NPI:1710519616
Name:SCOTT, ELISHA
Entity Type:Individual
Prefix:MR
First Name:ELISHA
Middle Name:
Last Name:SCOTT
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 1:1345 HARDEMAN AVE APT 415A
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-4403
Mailing Address - Country:US
Mailing Address - Phone:912-224-0560
Mailing Address - Fax:
Practice Address - Street 1:1345 HARDEMAN AVE APT 415A
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-4403
Practice Address - Country:US
Practice Address - Phone:912-224-0560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-08
Last Update Date:2020-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program