Basic Information
| Provider Information | |||||||||
| NPI: | 1245670736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERRON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | BLODNICK | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1930 W BROADWAY ST | ||||||||
| Address2: | STE A | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065416844 | ||||||||
| FaxNumber: | 4177197896 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 W 8TH AVE | ||||||||
| Address2: | SUITE 7050 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092521711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2013 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3719 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MED-PAC-LIC-49941 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA60610762 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.