Provider Demographics
NPI:1902303670
Name:HOFSTADTER, SCOTT ALLEN
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALLEN
Last Name:HOFSTADTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 593
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-0593
Mailing Address - Country:US
Mailing Address - Phone:612-805-8270
Mailing Address - Fax:612-805-8270
Practice Address - Street 1:2160 DEER RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-0593
Practice Address - Country:US
Practice Address - Phone:612-805-8270
Practice Address - Fax:612-805-8270
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA445225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant