Provider Demographics
NPI:1427409309
Name:SCANLON, AIDA E (PA)
Entity type:Individual
Prefix:
First Name:AIDA
Middle Name:E
Last Name:SCANLON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3445 S DIXIE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-2330
Mailing Address - Country:US
Mailing Address - Phone:937-534-0155
Mailing Address - Fax:937-534-0166
Practice Address - Street 1:3445 S DIXIE DR
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439
Practice Address - Country:US
Practice Address - Phone:937-534-0155
Practice Address - Fax:937-534-0166
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000999RX363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid