Healthcare Provider Details

I. General information

NPI: 1912087438
Provider Name (Legal Business Name): TARA C ROTHWELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
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 4114
PASADENA CA
91110-4114
US

V. Phone/Fax

Practice location:
  • Phone: 406-543-7271
  • Fax: 406-327-1834
Mailing address:
  • Phone: 406-543-7271
  • Fax: 406-327-1834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA669
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMED-PAC-LIC-35982
License Number StateMT
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA574
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: