Provider Demographics
NPI:1205877842
Name:TATUM, SCOTT A
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:TATUM
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 1:127 S 500 E
Mailing Address - Street 2:SUITE 600
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1971
Mailing Address - Country:US
Mailing Address - Phone:801-587-6336
Mailing Address - Fax:801-715-8228
Practice Address - Street 1:1160 E 3900 S
Practice Address - Street 2:SUITE 2000
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1202
Practice Address - Country:US
Practice Address - Phone:801-266-3418
Practice Address - Fax:801-288-4444
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT377832-1206363AS0400X
GA10064363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS92546Medicare UPIN