Provider Demographics
NPI:1497925135
Name:SIMS, SCOTT G (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:G
Last Name:SIMS
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:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3640 NW SAMARITAN DR STE 120
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3738
Practice Address - Country:US
Practice Address - Phone:541-768-5223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002083363AS0400X
VA0110002857363AS0400X
CO3418363AS0400X
ORPA179815363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1497925135Medicaid
VA1497925135Medicaid