Provider Demographics
NPI:1760764054
Name:SKOVLY, CRYSTAL L (PAC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:SKOVLY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 HIGHLAND BLVD
Mailing Address - Street 2:ATTN PFS CREDENTIALING
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6902
Mailing Address - Country:US
Mailing Address - Phone:406-414-5000
Mailing Address - Fax:
Practice Address - Street 1:1 BOBCAT CIRCLE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3380
Practice Address - Country:US
Practice Address - Phone:406-414-4780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT65940363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1760764054Medicaid