Provider Demographics
NPI:1194251520
Name:SCOTT, WILLIE ANDREW (RT)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:ANDREW
Last Name:SCOTT
Suffix:
Gender:M
Credentials:RT
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 594593
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054
Mailing Address - Country:US
Mailing Address - Phone:918-813-0442
Mailing Address - Fax:
Practice Address - Street 1:5427 MAVERICK DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-2638
Practice Address - Country:US
Practice Address - Phone:918-813-0442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies