Provider Demographics
NPI:1891242012
Name:SCANLON, PETER ANDREW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:ANDREW
Last Name:SCANLON
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 1:3023 E SELLS DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5845
Mailing Address - Country:US
Mailing Address - Phone:623-217-1015
Mailing Address - Fax:
Practice Address - Street 1:3023 E SELLS DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5845
Practice Address - Country:US
Practice Address - Phone:623-217-1015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant