Provider Demographics
NPI:1548293558
Name:POAG, SCOTT D (PA-C)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:D
Last Name:POAG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03756-0001
Mailing Address - Country:US
Mailing Address - Phone:603-650-5000
Mailing Address - Fax:
Practice Address - Street 1:89 W COPELAND DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2002
Practice Address - Country:US
Practice Address - Phone:321-841-7550
Practice Address - Fax:321-841-8185
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHEL11614363A00000X
FLPA 9102866363AS0400X
NJ25MP00783100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHF826AOtherMEDICARE GRP PTAN
FL292096400Medicaid
FLHF826AOtherMEDICARE GRP PTAN
FLQ26144Medicare UPIN
FL292096400Medicaid