Basic Information
Provider Information | |||||||||
NPI: | 1306890041 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEIGERT | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | CAROLINE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WOZNY | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | CAROLINE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PAC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1233 N 30TH ST | ||||||||
Address2: |   | ||||||||
City: | BILLINGS | ||||||||
State: | MT | ||||||||
PostalCode: | 591010127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4062382500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2800 10TH AVE N | ||||||||
Address2: |   | ||||||||
City: | BILLINGS | ||||||||
State: | MT | ||||||||
PostalCode: | 591010703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4066574000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2006 | ||||||||
LastUpdateDate: | 02/27/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/27/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 450 | MT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 000097213 | 01 | MT | BCBS PIN | OTHER | 123054900 | 01 | WY | MDCD PIN | OTHER |