Provider Demographics
NPI:1154655777
Name:RACICOT, KATHLEEN MARKLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARKLE
Last Name:RACICOT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2740 SOUTH AVENUE WEST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-5137
Mailing Address - Country:US
Mailing Address - Phone:406-728-6101
Mailing Address - Fax:406-721-3278
Practice Address - Street 1:2740 SOUTH AVENUE WEST
Practice Address - Street 2:SUITE 101
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-5137
Practice Address - Country:US
Practice Address - Phone:406-728-6101
Practice Address - Fax:406-721-3278
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2019-02-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MT31214363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant