1679653745 NPI number — MR. SCOTT MATTHEW LIGHT P.A.-C.

Table of content: MR. SCOTT MATTHEW LIGHT P.A.-C. (NPI 1679653745)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679653745 NPI number — MR. SCOTT MATTHEW LIGHT P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIGHT
Provider First Name:
SCOTT
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679653745
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
838 ESSEX AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98520-2718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-730-6719
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1251 NE ELM ST
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
PRINEVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97754-1206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-447-1680
Provider Business Practice Location Address Fax Number:
541-447-4670
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA01153 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA10005254 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA01153 . This is a "OREGON STATE LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 213187 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: PA10005254 . This is a "WA LICENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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