Basic Information
| Provider Information | |||||||||
| NPI: | 1073656682 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2360 MULLAN RD STE C | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067214436 | ||||||||
| FaxNumber: | 4065421037 | ||||||||
| Practice Location | |||||||||
| Address1: | 2360 MULLAN RD STE C | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067214436 | ||||||||
| FaxNumber: | 4065421037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
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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 | 363LF0000X | RN18519 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0439998 | 05 | MT | MEDICAID | 500027942 CK5082 | 01 | RAILROAD MEDICARE | OTHER | 000372730 | 01 | MT | BLUE CROSS BLUE SHIELD | OTHER | 806516800 | 05 | ID | MEDICAID |