Basic Information
| Provider Information | |||||||||
| NPI: | 1437448958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELY | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 S LAVENTURE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982746033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604247041 | ||||||||
| FaxNumber: | 4253398273 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 CONTINENTAL PL | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982734105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604247041 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2011 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA60198949 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA60198949 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2012072 | 05 | WA | MEDICAID |