Provider Demographics
NPI:1851647044
Name:EDEGBE, SCOTT A (FNP-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:EDEGBE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W TERRELL AVE STE K230
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2820
Mailing Address - Country:US
Mailing Address - Phone:817-250-4906
Mailing Address - Fax:817-250-1815
Practice Address - Street 1:1300 W TERRELL AVE STE K230
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2820
Practice Address - Country:US
Practice Address - Phone:817-250-4906
Practice Address - Fax:817-250-1815
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP122019363LF0000X
TX828460363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX308590403Medicaid
TX308590402Medicaid
TX308590402Medicaid
TX275600YKPWMedicare PIN