Basic Information
| Provider Information | |||||||||
| NPI: | 1750533071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | CARIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 W SPRUCE ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063295746 | ||||||||
| FaxNumber: | 4063271697 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W SPRUCE ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598024057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063295746 | ||||||||
| FaxNumber: | 4063271697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2008 | ||||||||
| LastUpdateDate: | 06/21/2013 | ||||||||
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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 | 363AM0700X | 19670 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | MED-PAC-LIC-24421 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | M000009936 | 01 | MT | MEDICARE PTAN | OTHER |