Provider Demographics
NPI:1700305174
Name:BULL, ADRIENNE (PA-C)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:
Last Name:BULL
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 1:445 CENTENNIAL AVE
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-2870
Mailing Address - Country:US
Mailing Address - Phone:406-723-4075
Mailing Address - Fax:406-496-6035
Practice Address - Street 1:41 BARRETT ST
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:MT
Practice Address - Zip Code:59725-3508
Practice Address - Country:US
Practice Address - Phone:406-683-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-16
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-58472363A00000X
AZ6933363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ319718Medicaid