Provider Demographics
NPI:1780144469
Name:SPRAGUE, MARINA MUDD
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:MUDD
Last Name:SPRAGUE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6902
Mailing Address - Country:US
Mailing Address - Phone:406-414-5000
Mailing Address - Fax:
Practice Address - Street 1:206 ALASKA FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-7909
Practice Address - Country:US
Practice Address - Phone:406-414-3334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-127105207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine