Healthcare Provider Details

I. General information

NPI: 1841067832
Provider Name (Legal Business Name): MARISA RENEE LLAMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 SOUTH AVE W STE 101
MISSOULA MT
59804-5137
US

IV. Provider business mailing address

60386 E LOOSE REINS PL
TUCSON AZ
85739-5903
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-6101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMED-PAC-LIC-144583-
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: