Healthcare Provider Details

I. General information

NPI: 1285902767
Provider Name (Legal Business Name): LISA MICHELLE WEINREICH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 10/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 E MAIN ST
MISSOULA MT
59802-4423
US

IV. Provider business mailing address

PO BOX 7024
MISSOULA MT
59807-7024
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-5490
  • Fax: 406-728-5497
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number677
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: