Basic Information
| Provider Information | |||||||||
| NPI: | 1255482683 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ASTLEY | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1789 S BROADWAY AVE | ||||||||
| Address2: | STE 100 | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703249722 | ||||||||
| FaxNumber: | 2084825505 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | SUITE 370 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702212290 | ||||||||
| FaxNumber: | 9702212293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2007 | ||||||||
| LastUpdateDate: | 03/08/2017 | ||||||||
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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 | 363AM0700X | 2365 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | P00750757 | 01 | CO | RR MEDICARE | OTHER | 82377774 | 05 | CO | MEDICAID |