Provider Demographics
NPI:1245670736
Name:HERRON, ELIZABETH BLODNICK (PA)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:BLODNICK
Last Name:HERRON
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1930 W BROADWAY ST
Mailing Address - Street 2:STE A
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-1820
Mailing Address - Country:US
Mailing Address - Phone:406-541-6844
Mailing Address - Fax:417-719-7896
Practice Address - Street 1:105 W 8TH AVE
Practice Address - Street 2:SUITE 7050
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2302
Practice Address - Country:US
Practice Address - Phone:509-252-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2021-08-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO3719363A00000X
MTMED-PAC-LIC-49941363A00000X
WAPA60610762363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant