Healthcare Provider Details

I. General information

NPI: 1962461442
Provider Name (Legal Business Name): SCOTT P SHERRY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N GRAHAM STE 580
PORTLAND OR
97227-2003
US

IV. Provider business mailing address

501 N GRAHAM STE 580
PORTLAND OR
97227-2003
US

V. Phone/Fax

Practice location:
  • Phone: 503-528-0704
  • Fax: 503-528-0708
Mailing address:
  • Phone: 503-528-0704
  • Fax: 503-528-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00859
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: