Healthcare Provider Details

I. General information

NPI: 1619420494
Provider Name (Legal Business Name): JESSICA HOLTROP BALIS PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 04/20/2025
Certification Date: 04/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST
MISSOULA MT
59802-4008
US

IV. Provider business mailing address

PO BOX 31001-4110
PASADENA CA
91110-4110
US

V. Phone/Fax

Practice location:
  • Phone: 406-329-5615
  • Fax:
Mailing address:
  • Phone: 866-747-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMED-PAC-LIC-60155
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: