Healthcare Provider Details

I. General information

NPI: 1497925135
Provider Name (Legal Business Name): SCOTT G SIMS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 NW SAMARITAN DR STE 120
CORVALLIS OR
97330-3738
US

IV. Provider business mailing address

PO BOX 1189
CORVALLIS OR
97339-1189
US

V. Phone/Fax

Practice location:
  • Phone: 541-768-5223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number002083
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110002857
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3418
License Number StateCO
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA179815
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: