Provider Demographics
NPI:1942205190
Name:WILLIAMS, SCOT T (PA)
Entity Type:Individual
Prefix:MR
First Name:SCOT
Middle Name:T
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:SCOT
Other - Middle Name:T
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1034 MAR WALT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6645
Mailing Address - Country:US
Mailing Address - Phone:850-315-9213
Mailing Address - Fax:850-315-9350
Practice Address - Street 1:1034 MAR WALT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6645
Practice Address - Country:US
Practice Address - Phone:850-315-9213
Practice Address - Fax:850-315-9350
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103018363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1467583010OtherMEDICARE NPI GROUP
FL002879600Medicaid
FL1467589010Medicaid
FLDC690AOtherMEDICARE GROUP PIN
FLQ36738Medicare UPIN
FL002879600Medicaid
FLDC690AOtherMEDICARE GROUP PIN