Provider Demographics
NPI:1053823047
Name:CLEMONS, SCOTT JEFFREY (NP-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:JEFFREY
Last Name:CLEMONS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9537 GRAVELLY LAKE DR SW
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-1513
Mailing Address - Country:US
Mailing Address - Phone:253-984-2000
Mailing Address - Fax:253-984-2049
Practice Address - Street 1:9537 GRAVELLY LAKE DR SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-1513
Practice Address - Country:US
Practice Address - Phone:253-984-2000
Practice Address - Fax:253-984-2049
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60799444363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2090261Medicaid