Healthcare Provider Details

I. General information

NPI: 1174973564
Provider Name (Legal Business Name): JACOB WHEELER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2016
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 HIGHLAND BLVD STE 1100
BOZEMAN MT
59715-6900
US

IV. Provider business mailing address

915 HIGHLAND BLVD ATTN PFS CREDENTIALING
BOZEMAN MT
59715-6902
US

V. Phone/Fax

Practice location:
  • Phone: 406-414-4550
  • Fax:
Mailing address:
  • Phone: 406-414-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number79505
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: