Healthcare Provider Details

I. General information

NPI: 1205266053
Provider Name (Legal Business Name): TYLER WAGSTAFF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2013
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 HERITAGE WAY STE 202
KALISPELL MT
59901-3127
US

IV. Provider business mailing address

350 HERITAGE WAY STE 2100
KALISPELL MT
59901-3167
US

V. Phone/Fax

Practice location:
  • Phone: 406-752-8433
  • Fax: 406-756-6768
Mailing address:
  • Phone: 406-257-8992
  • Fax: 406-257-8996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA1227
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMED-PAC-LIC-79860
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: