Provider Demographics
NPI:1487906814
Name:SCANLAN, CHRISTINA S (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:S
Last Name:SCANLAN
Suffix:
Gender:F
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 1:1834 W 34TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16508-2110
Mailing Address - Country:US
Mailing Address - Phone:801-419-2079
Mailing Address - Fax:
Practice Address - Street 1:118 9TH AVE N
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-6352
Practice Address - Country:US
Practice Address - Phone:208-537-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064678363A00000X
IDPA-1009363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1013204957Medicaid
ID1013204957Medicaid