Provider Demographics
NPI:1528533296
Name:STUART, SCOTT CORY (PA-C)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:CORY
Last Name:STUART
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:147 W CHUBBUCK RD
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2314
Mailing Address - Country:US
Mailing Address - Phone:208-238-7546
Mailing Address - Fax:208-237-9643
Practice Address - Street 1:1344 HILAND AVE STE D
Practice Address - Street 2:
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-1564
Practice Address - Country:US
Practice Address - Phone:208-572-6005
Practice Address - Fax:208-261-3066
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2020-02-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA-1850363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty