Provider Demographics
NPI:1356535322
Name:MATHIS, SCOTT (APRN,BC)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:MATHIS
Suffix:
Gender:M
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E CARTER AVE
Mailing Address - Street 2:
Mailing Address - City:BLACKSHEAR
Mailing Address - State:GA
Mailing Address - Zip Code:31516-1561
Mailing Address - Country:US
Mailing Address - Phone:912-449-1501
Mailing Address - Fax:912-449-1517
Practice Address - Street 1:1218 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4525
Practice Address - Country:US
Practice Address - Phone:912-284-9800
Practice Address - Fax:912-284-1711
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN00138004363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner