Provider Demographics
NPI:1750533071
Name:DOUGHERTY, CARIN (PA-C)
Entity type:Individual
Prefix:MISS
First Name:CARIN
Middle Name:
Last Name:DOUGHERTY
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 1:601 W SPRUCE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4057
Mailing Address - Country:US
Mailing Address - Phone:406-329-5746
Mailing Address - Fax:406-327-1697
Practice Address - Street 1:601 W SPRUCE ST
Practice Address - Street 2:SUITE C
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4057
Practice Address - Country:US
Practice Address - Phone:406-329-5746
Practice Address - Fax:406-327-1697
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19670363AM0700X
MTMED-PAC-LIC-24421363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM000009936OtherMEDICARE PTAN