Basic Information
| Provider Information | |||||||||
| NPI: | 1891722302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCALLON | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | |||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3411 N 5TH AVE STE 209 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027890344 | ||||||||
| FaxNumber: | 6027898389 | ||||||||
| Practice Location | |||||||||
| Address1: | 3411 N 5TH AVE STE 209 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850133812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027890344 | ||||||||
| FaxNumber: | 6027898389 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 01/16/2018 | ||||||||
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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 | 363A00000X | 2563 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 634370 | 05 | AZ | MEDICAID |