Basic Information
| Provider Information | |||||||||
| NPI: | 1265486914 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOODARD | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 PAVILION DR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233926343 | ||||||||
| FaxNumber: | 4233926159 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 PAVILION DR | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233926343 | ||||||||
| FaxNumber: | 4233926159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 142489 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1512151 | 05 | TN | MEDICAID |