Provider Demographics
NPI:1255482683
Name:ASTLEY, SCOTT MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:ASTLEY
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 1:8854 W EMERALD ST STE 290
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4846
Mailing Address - Country:US
Mailing Address - Phone:208-296-7500
Mailing Address - Fax:208-296-7501
Practice Address - Street 1:8854 W EMERALD ST STE 290
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-4846
Practice Address - Country:US
Practice Address - Phone:208-296-7500
Practice Address - Fax:208-296-7501
Is Sole Proprietor?:No
Enumeration Date:2007-01-14
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2365363AM0700X
IDPA-1370363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00750757OtherRR MEDICARE
ID1255482683Medicaid
CO82377774Medicaid
COP00750757OtherRR MEDICARE