Provider Demographics
NPI:1174568109
Name:SCOTT, KERRY ANNE (PA)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:ANNE
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656 ADELINE DR
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-2344
Mailing Address - Country:US
Mailing Address - Phone:585-730-3992
Mailing Address - Fax:585-247-0075
Practice Address - Street 1:615 S HUGHES BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4785
Practice Address - Country:US
Practice Address - Phone:252-338-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7084363AM0700X
NY007084363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02393635Medicaid
NYJ400169232/GRPBA0017Medicare PIN
NY02393635Medicaid