Provider Demographics
NPI:1598837239
Name:BROWN, CODY (PA-C)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:BROWN
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 1:6 13TH AVE E
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-5315
Mailing Address - Country:US
Mailing Address - Phone:406-883-8432
Mailing Address - Fax:406-883-8255
Practice Address - Street 1:6 13TH AVE E
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-5315
Practice Address - Country:US
Practice Address - Phone:406-883-8432
Practice Address - Fax:406-883-8255
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT276363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT4306202Medicaid
MT4306202Medicaid