Provider Demographics
NPI:1316192008
Name:SCOGGIN, KALA RICHELLE (PA)
Entity type:Individual
Prefix:
First Name:KALA
Middle Name:RICHELLE
Last Name:SCOGGIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KALA
Other - Middle Name:RICHELLE
Other - Last Name:SHUTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1155 MILL ST # M14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:975 RYLAND ST STE 100
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1669
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-5225
Is Sole Proprietor?:No
Enumeration Date:2008-11-21
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1540363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1316192008Medicaid
12729842OtherCAQH
NV1316192008Medicaid
NVV111363Medicare PIN
NVV108475Medicare PIN