Provider Demographics
NPI:1386245579
Name:SCOTT, GLEN (PA-C)
Entity type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:SCOTT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2333 W HILLSBOROUGH AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-1061
Mailing Address - Country:US
Mailing Address - Phone:813-660-6300
Mailing Address - Fax:813-660-6620
Practice Address - Street 1:2333 W HILLSBOROUGH AVE STE 160
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-1061
Practice Address - Country:US
Practice Address - Phone:813-660-6300
Practice Address - Fax:813-660-6620
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113805363A00000X
FL17663207R00000X
MI5601011920363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601011920OtherMI PHYSICIAN ASSISTANT LICENSE
MI5315245193OtherMICHIGAN CONTROLLED SUBSTANCE LICENSE