Provider Demographics
NPI:1760568869
Name:NIEMAN, DAVID L (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:NIEMAN
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 1:107 DILWORTH ST
Mailing Address - Street 2:
Mailing Address - City:GLENDIVE
Mailing Address - State:MT
Mailing Address - Zip Code:59330-2053
Mailing Address - Country:US
Mailing Address - Phone:406-345-8935
Mailing Address - Fax:406-345-8908
Practice Address - Street 1:107 DILWORTH ST
Practice Address - Street 2:
Practice Address - City:GLENDIVE
Practice Address - State:MT
Practice Address - Zip Code:59330-2053
Practice Address - Country:US
Practice Address - Phone:406-345-8935
Practice Address - Fax:406-345-8908
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004978363AM0700X
MT363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0207865OtherL&I
WA8941215OtherL&I CVC
WA8500225Medicaid
WA9947NIOtherREGENCE RIDER
WA8941215OtherL&I CVC
WAQ68624Medicare UPIN