Provider Demographics
NPI:1033111521
Name:SCOTT, STEPHANIE R (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:R
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:R
Other - Last Name:CONOLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 5579
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97708-5579
Mailing Address - Country:US
Mailing Address - Phone:541-706-6905
Mailing Address - Fax:541-706-6906
Practice Address - Street 1:2042 NE WILLIAMSON CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3760
Practice Address - Country:US
Practice Address - Phone:541-706-6905
Practice Address - Fax:541-706-6906
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01424363A00000X
AZ2730363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ738338Medicaid
OR500605527Medicaid
AZP00275877Medicare PIN
OR500605527Medicaid
AZZ72690Medicare PIN
ORR145455Medicare PIN