Provider Demographics
NPI:1073656682
Name:PETERSON, PAMELA B (NP)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:B
Last Name:PETERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 MULLAN RD STE C
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1811
Mailing Address - Country:US
Mailing Address - Phone:406-721-4436
Mailing Address - Fax:406-542-1037
Practice Address - Street 1:2360 MULLAN RD STE C
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1811
Practice Address - Country:US
Practice Address - Phone:406-721-4436
Practice Address - Fax:406-542-1037
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTRN18519363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0439998Medicaid
500027942 CK5082OtherRAILROAD MEDICARE
MT000372730OtherBLUE CROSS BLUE SHIELD
ID806516800Medicaid
ID806516800Medicaid
MT000372730OtherBLUE CROSS BLUE SHIELD