Provider Demographics
NPI:1942354766
Name:SUTPHIN, SCOTT A (PTA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:SUTPHIN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 SHENANDOAH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24017-4749
Mailing Address - Country:US
Mailing Address - Phone:540-982-2860
Mailing Address - Fax:
Practice Address - Street 1:4550 SHENANDOAH AVE NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-4749
Practice Address - Country:US
Practice Address - Phone:540-982-2860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602211225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant