Provider Demographics
NPI:1922168517
Name:LILLY, JAMIE MARIA (PA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:MARIA
Last Name:LILLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:MARIA
Other - Last Name:MCCORMACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WORTMAN
Mailing Address - Street 1:500 WEST BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4096
Mailing Address - Country:US
Mailing Address - Phone:406-329-5615
Mailing Address - Fax:406-329-2791
Practice Address - Street 1:500 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802
Practice Address - Country:US
Practice Address - Phone:406-329-5615
Practice Address - Fax:406-329-2791
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0031195363AM0700X
NC001000729363AS0400X
NH0670363AS0400X
MT69994363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT9000375Medicaid
NH30207723Medicaid
NC2767903Medicare PIN
VT9000375Medicaid
NH30207723Medicaid