Provider Demographics
NPI:1386613883
Name:SCOTT, KIMBERLEY J (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:J
Last Name:SCOTT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:9701 SW BARNES RD STE 300
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6689
Practice Address - Country:US
Practice Address - Phone:503-297-8081
Practice Address - Fax:503-292-6601
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6382363AM0700X
ORPA204268363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8450082Medicaid
WA8941182OtherCRIME VICTIMS
WA0207736OtherLABOR & IND
OR500604767Medicaid
P00336906OtherRR MEDICARE
S67153Medicare UPIN