Provider Demographics
NPI:1750839080
Name:ROQUEMORE, SCOTT (ATC, EMT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:ROQUEMORE
Suffix:
Gender:M
Credentials:ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25621 PURPLE SAGE LN
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-4322
Mailing Address - Country:US
Mailing Address - Phone:949-636-6872
Mailing Address - Fax:
Practice Address - Street 1:25621 PURPLE SAGE LN
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-4322
Practice Address - Country:US
Practice Address - Phone:949-636-6872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA146N00000X
CA2000011868390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic