Provider Demographics
NPI:1083092514
Name:WIMMER, SHELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:
Last Name:WIMMER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 MONMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OR
Mailing Address - Zip Code:97351-1127
Mailing Address - Country:US
Mailing Address - Phone:503-838-1133
Mailing Address - Fax:503-838-5138
Practice Address - Street 1:1430 MONMOUTH ST
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OR
Practice Address - Zip Code:97351-1127
Practice Address - Country:US
Practice Address - Phone:503-838-1133
Practice Address - Fax:503-838-5138
Is Sole Proprietor?:No
Enumeration Date:2015-05-17
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA 1779965363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1083092514OtherNPI