Provider Demographics
NPI:1881758217
Name:MATTOON, SCOTT (PA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:MATTOON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 PRE EMPTION RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-2042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:875 PRE EMPTION RD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-2042
Practice Address - Country:US
Practice Address - Phone:315-462-2633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0072521363A00000X
NY007252363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P019P12657OtherBLUECHOICE
110561CUOtherPREFERRED CARE
NYPA1653Medicare PIN