Healthcare Provider Details

I. General information

NPI: 1124532155
Provider Name (Legal Business Name): TONY GORDON BALLENSKY FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 S CRYSTAL ST STE 300
BUTTE MT
59701-1506
US

IV. Provider business mailing address

3204 PHILLIPS ST
BUTTE MT
59701-4526
US

V. Phone/Fax

Practice location:
  • Phone: 406-496-3600
  • Fax:
Mailing address:
  • Phone: 406-490-0756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number128284
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: