Healthcare Provider Details

I. General information

NPI: 1922168517
Provider Name (Legal Business Name): JAMIE MARIA LILLY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JAMIE MARIA MCCORMACK WORTMAN

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WEST BROADWAY
MISSOULA MT
59802
US

IV. Provider business mailing address

500 WEST BROADWAY
MISSOULA MT
59802-4096
US

V. Phone/Fax

Practice location:
  • Phone: 406-329-5615
  • Fax: 406-329-2791
Mailing address:
  • Phone: 406-329-5615
  • Fax: 406-329-2791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number69994
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number055-0031195
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number001000729
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0670
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: