Provider Demographics
NPI:1396793303
Name:CAMPBELL, SCOTTY J (CRNA)
Entity type:Individual
Prefix:
First Name:SCOTTY
Middle Name:J
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601549
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1549
Mailing Address - Country:US
Mailing Address - Phone:704-384-4239
Mailing Address - Fax:704-384-5636
Practice Address - Street 1:13808 PROFESSIONAL CENTER DR
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7948
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC073328367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052348Medicaid
SCNAN585Medicaid
2609649Medicare ID - Type Unspecified
NC8052348Medicaid