Provider Demographics
NPI:1245251230
Name:DEARMOND, NICOLE C (PA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:C
Last Name:DEARMOND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 ALPENGLOW LN
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-8506
Mailing Address - Country:US
Mailing Address - Phone:406-222-3541
Mailing Address - Fax:
Practice Address - Street 1:309 ELLIOT STREET NORTH
Practice Address - Street 2:
Practice Address - City:WILSALL
Practice Address - State:MT
Practice Address - Zip Code:59086-0347
Practice Address - Country:US
Practice Address - Phone:406-578-2222
Practice Address - Fax:406-578-2174
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1883-023363A00000X, 363AM0700X, 363AS0400X
MTMED-PAC-LIC-41544363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1245251230Medicaid
MT1245251230Medicaid
MT011001658Medicare PIN
WI000471215Medicare ID - Type Unspecified