Basic Information
| Provider Information | |||||||||
| NPI: | 1093023418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL | ||||||||
| FirstName: | DYLAN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1224 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598402338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063754823 | ||||||||
| FaxNumber: | 4063754846 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 WESTWOOD DR | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598402345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063630597 | ||||||||
| FaxNumber: | 4063754858 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2010 | ||||||||
| LastUpdateDate: | 09/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 632 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 011003812 | 01 | MT | GROUP | OTHER |