Provider Demographics
NPI:1457631863
Name:GIOVENCO, SALVATORE (PA-C)
Entity Type:Individual
Prefix:
First Name:SALVATORE
Middle Name:
Last Name:GIOVENCO
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 1:2442 WINNE AVE
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59601-4921
Mailing Address - Country:US
Mailing Address - Phone:406-457-4100
Mailing Address - Fax:406-457-4110
Practice Address - Street 1:2442 WINNE AVE
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4921
Practice Address - Country:US
Practice Address - Phone:406-457-4100
Practice Address - Fax:406-457-4110
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MTMED-PAC-LIC-34951363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1457631863Medicaid