Provider Demographics
NPI:1184989634
Name:SKOTNICKI, TESSA CAITLIN (PA)
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:CAITLIN
Last Name:SKOTNICKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TESSA
Other - Middle Name:CAITLIN
Other - Last Name:BEITZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:320 SUNNYVIEW LN
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3129
Mailing Address - Country:US
Mailing Address - Phone:406-752-7441
Mailing Address - Fax:406-257-0304
Practice Address - Street 1:320 SUNNYVIEW LN
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3129
Practice Address - Country:US
Practice Address - Phone:406-752-7441
Practice Address - Fax:406-257-0304
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV574363A00000X
NMPA2013-0093363AM0700X
MT57605363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM75658071Medicaid
NM75658071Medicaid