Provider Demographics
NPI:1942590583
Name:LIMONCELLI, MARA CHRISTINE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MARA
Middle Name:CHRISTINE
Last Name:LIMONCELLI
Suffix:
Gender:F
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 1:1006 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-3219
Mailing Address - Country:US
Mailing Address - Phone:406-414-4800
Mailing Address - Fax:
Practice Address - Street 1:1006 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3219
Practice Address - Country:US
Practice Address - Phone:406-414-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-17
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA158092207N00000X, 363A00000X
MT104134363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500705178Medicaid