Provider Demographics
NPI:1295836831
Name:MATTINGLY, ADAM R (PA-C)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:R
Last Name:MATTINGLY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 N 27TH ST
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59101-0711
Mailing Address - Country:US
Mailing Address - Phone:406-237-8855
Mailing Address - Fax:
Practice Address - Street 1:1027 N 27TH ST
Practice Address - Street 2:
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-0711
Practice Address - Country:US
Practice Address - Phone:406-237-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY356363A00000X
MT508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY102405100Medicaid
WY612315900OtherOWCP
MT000900383OtherBCBS PIN
WY315012OtherBCBS
MT000900383OtherBCBS PIN
WY102405100Medicaid
MT011000897Medicare PIN