Provider Demographics
NPI:1275669806
Name:ITOMURA, SCOT SHOICHI (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SCOT
Middle Name:SHOICHI
Last Name:ITOMURA
Suffix:
Gender:M
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 1:1013 SW GAINES ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2975
Mailing Address - Country:US
Mailing Address - Phone:503-721-0828
Mailing Address - Fax:
Practice Address - Street 1:17704 JEAN WAY
Practice Address - Street 2:STE 101
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5497
Practice Address - Country:US
Practice Address - Phone:503-699-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01184363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant