Provider Demographics
NPI:1437448958
Name:ELY, SCOTT MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MICHAEL
Last Name:ELY
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 1:1401 S LAVENTURE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-6033
Mailing Address - Country:US
Mailing Address - Phone:360-424-7041
Mailing Address - Fax:425-339-8273
Practice Address - Street 1:1500 CONTINENTAL PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-4105
Practice Address - Country:US
Practice Address - Phone:360-424-7041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60198949363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2012072Medicaid