Provider Demographics
NPI:1114956190
Name:WILEY, JAMES BRYCE (PAC)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BRYCE
Last Name:WILEY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:931 HIGHLAND BLVD
Mailing Address - Street 2:SUITE 3260
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6911
Mailing Address - Country:US
Mailing Address - Phone:406-414-2410
Mailing Address - Fax:406-414-5198
Practice Address - Street 1:931 HIGHLAND BLVD
Practice Address - Street 2:SUITE 3260
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6911
Practice Address - Country:US
Practice Address - Phone:406-414-2410
Practice Address - Fax:406-414-5198
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT444363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4307732Medicaid
MT85157Medicare ID - Type Unspecified
MTP85172Medicare UPIN