Basic Information
| Provider Information | |||||||||
| NPI: | 1083092514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIMMER | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 MONMOUTH ST | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973511127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038381133 | ||||||||
| FaxNumber: | 5038385138 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 MONMOUTH ST | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973511127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038381133 | ||||||||
| FaxNumber: | 5038385138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2015 | ||||||||
| LastUpdateDate: | 03/29/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA 1779965 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1083092514 | 01 | OR | NPI | OTHER |