Healthcare Provider Details

I. General information

NPI: 1093630444
Provider Name (Legal Business Name): MARISA PEOT PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 GREAT NORTHERN AVE APT L14
MISSOULA MT
59808-1720
US

IV. Provider business mailing address

2200 GREAT NORTHERN AVE APT L14
MISSOULA MT
59808-1720
US

V. Phone/Fax

Practice location:
  • Phone: 262-751-3446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMED-PAC-LIC-174265
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: