Provider Demographics
NPI:1578598850
Name:SCOTT, MCKENNETH JR (PHYSICIANS ASSISTANT)
Entity type:Individual
Prefix:
First Name:MCKENNETH
Middle Name:
Last Name:SCOTT
Suffix:JR
Gender:M
Credentials:PHYSICIANS ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 JOHN PAUL JONES CIR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23708-2111
Mailing Address - Country:US
Mailing Address - Phone:757-953-3933
Mailing Address - Fax:757-953-3890
Practice Address - Street 1:1750 TOMCAT BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23460-2168
Practice Address - Country:US
Practice Address - Phone:757-953-3933
Practice Address - Fax:757-953-3890
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2025-01-17
Deactivation Date:2006-07-19
Deactivation Code:
Reactivation Date:2006-11-16
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NY006243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01903075Medicaid
S71631Medicare UPIN
NY01903075Medicaid