Provider Demographics
NPI:1629872163
Name:SCHULTZ, SCOTT LOUIS
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:LOUIS
Last Name:SCHULTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 BAYPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1849
Mailing Address - Country:US
Mailing Address - Phone:631-603-7023
Mailing Address - Fax:
Practice Address - Street 1:75 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2190
Practice Address - Country:US
Practice Address - Phone:631-473-1320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPENDING367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered