Provider Demographics
NPI:1912915687
Name:HERMILLER, STACY C (PAC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:C
Last Name:HERMILLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:JAMES
Other - Last Name:CHRISTENSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6010
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59406-6010
Mailing Address - Country:US
Mailing Address - Phone:406-454-2171
Mailing Address - Fax:406-771-3021
Practice Address - Street 1:1401 25TH ST S
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5183
Practice Address - Country:US
Practice Address - Phone:406-731-8888
Practice Address - Fax:406-731-8318
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT311363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1912915687Medicaid
MT000085487Medicare PIN
P93006Medicare UPIN