Basic Information
| Provider Information | |||||||||
| NPI: | 1578651717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON-SCOTT | ||||||||
| FirstName: | KARASA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8310 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240140310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Practice Location | |||||||||
| Address1: | 5875 BREMO RD | ||||||||
| Address2: | STE 212 | ||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232261934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045040530 | ||||||||
| FaxNumber: | 8045040532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 04/27/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 2201001214 | VA | Y | Speech, Language and Hearing Service Providers | Audiologist | 237700000X | 2101001461 | VA | N | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | MC11335 | 01 | VA | MEDICARE INDIVIDUAL PTAN | OTHER | 362423 | 01 | VA | ANTHEM | OTHER | 1578651717 | 05 | VA | MEDICAID |