Provider Demographics
NPI:1962850479
Name:MAESTAS, DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:MAESTAS
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 1:1501 SAINT CHARLES ST
Mailing Address - Street 2:
Mailing Address - City:FORT BENTON
Mailing Address - State:MT
Mailing Address - Zip Code:59442-7710
Mailing Address - Country:US
Mailing Address - Phone:406-622-5485
Mailing Address - Fax:
Practice Address - Street 1:1501 SAINT CHARLES ST
Practice Address - Street 2:
Practice Address - City:FORT BENTON
Practice Address - State:MT
Practice Address - Zip Code:59442-7710
Practice Address - Country:US
Practice Address - Phone:406-622-3331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004901RX363AM0700X
MTMED-PAC-LIC-88688363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical