Provider Demographics
NPI:1679653745
Name:LIGHT, SCOTT MATTHEW (PA-C)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:MATTHEW
Last Name:LIGHT
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 1:838 ESSEX AVE
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-2718
Mailing Address - Country:US
Mailing Address - Phone:503-730-6719
Mailing Address - Fax:
Practice Address - Street 1:1251 NE ELM ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-1206
Practice Address - Country:US
Practice Address - Phone:541-447-1680
Practice Address - Fax:541-447-4670
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01153363AM0700X
WAPA10005254363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA01153OtherOREGON STATE LICENSE
OR213187Medicaid
WAPA10005254OtherWA LICENCE
OR213187Medicaid