Healthcare Provider Details

I. General information

NPI: 1730589300
Provider Name (Legal Business Name): KRISTA NIEZWAAG PA-C, DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 HIGHLAND BLVD
BOZEMAN MT
59715-6902
US

IV. Provider business mailing address

1625 N CAMPBELL AVE
TUCSON AZ
85719-4330
US

V. Phone/Fax

Practice location:
  • Phone: 406-414-5000
  • Fax:
Mailing address:
  • Phone: 520-694-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085005134
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR3766
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMED-PHYS-LIC-159836
License Number StateMT
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMED-PHYS-LIC-159836
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: