Basic Information
| Provider Information | |||||||||
| NPI: | 1669451779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCOUFALOS | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2690 SOUTHFIELD DR | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174034510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177411414 | ||||||||
| FaxNumber: | 7177414774 | ||||||||
| Practice Location | |||||||||
| Address1: | 2690 SOUTHFIELD DR | ||||||||
| Address2: | |||||||||
| City: | YORK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 174034510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177411414 | ||||||||
| FaxNumber: | 7177414774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 01/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA050727 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 7743394 | 05 | PA | MEDICAID |