Provider Demographics
NPI:1750337192
Name:LIGHTFOOT, SCOTT E (PA-C)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:E
Last Name:LIGHTFOOT
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:PO BOX 6423
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85246-6423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5810 W BEVERLY LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-1800
Practice Address - Country:US
Practice Address - Phone:623-312-3000
Practice Address - Fax:623-312-3060
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3049363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ945123Medicaid
AZ945123Medicaid
AZZ135487Medicare PIN