Healthcare Provider Details

I. General information

NPI: 1295156768
Provider Name (Legal Business Name): MADDIE JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADDIE HOLT PA-C

II. Dates (important events)

Enumeration Date: 12/30/2013
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 25TH ST S
GREAT FALLS MT
59405-5183
US

IV. Provider business mailing address

PO BOX 6010
GREAT FALLS MT
59406-6010
US

V. Phone/Fax

Practice location:
  • Phone: 406-731-8888
  • Fax: 406-731-8318
Mailing address:
  • Phone: 406-731-8888
  • Fax: 406-731-8318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number68225
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPT587
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTL587
License Number StateWY
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA587
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: