Provider Demographics
NPI:1902232937
Name:INTERWICZ, SCOTT R (PA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:INTERWICZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S ACADEMY RD
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-8727
Mailing Address - Country:US
Mailing Address - Phone:405-260-4245
Mailing Address - Fax:402-282-8237
Practice Address - Street 1:200 S ACADEMY RD
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-8727
Practice Address - Country:US
Practice Address - Phone:405-260-4245
Practice Address - Fax:402-282-8237
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant