Provider Demographics
NPI:1174543888
Name:SMALL, SCOTT ALAN (PA-C)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALAN
Last Name:SMALL
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 1:130 FISHER RD
Mailing Address - Street 2:BLD. A, SUITE 2-2
Mailing Address - City:BERLIN
Mailing Address - State:VT
Mailing Address - Zip Code:05602
Mailing Address - Country:US
Mailing Address - Phone:802-229-2663
Mailing Address - Fax:802-229-6645
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:BLD. A, SUITE 2-2
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602
Practice Address - Country:US
Practice Address - Phone:802-229-2663
Practice Address - Fax:802-229-6645
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030654363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AP6099Medicare ID - Type Unspecified
S19026Medicare UPIN