Provider Demographics
NPI:1215344619
Name:GANUCHEAU, SCOTT CHRISTOPHER (MSPAS, PA-C, ATC)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:CHRISTOPHER
Last Name:GANUCHEAU
Suffix:
Gender:M
Credentials:MSPAS, PA-C, ATC
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5145 SELLERS RD
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470-3405
Practice Address - Country:US
Practice Address - Phone:910-754-4441
Practice Address - Fax:910-754-5307
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6612255A2300X
NC363A00000X
NC0010-12026363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer