Healthcare Provider Details

I. General information

NPI: 1457605214
Provider Name (Legal Business Name): MADELYN WILEY BOYLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2012
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N ORANGE ST SUITE 304
MISSOULA MT
59802-2998
US

IV. Provider business mailing address

900 N ORANGE ST SUITE 304
MISSOULA MT
59802-2998
US

V. Phone/Fax

Practice location:
  • Phone: 406-327-3350
  • Fax: 406-327-3355
Mailing address:
  • Phone: 406-327-3350
  • Fax: 406-327-3355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number20470
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number20470
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: