Healthcare Provider Details

I. General information

NPI: 1083092514
Provider Name (Legal Business Name): SHELLY WIMMER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2015
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 FAIRVIEW ST
SILVERTON OR
97381-1916
US

IV. Provider business mailing address

PO BOX 3417
PORTLAND OR
97208-3417
US

V. Phone/Fax

Practice location:
  • Phone: 503-874-5625
  • Fax: 503-874-5652
Mailing address:
  • Phone: 503-413-3900
  • Fax: 503-413-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA179965
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 1779965
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: