Healthcare Provider Details

I. General information

NPI: 1952395758
Provider Name (Legal Business Name): PAULA S COLLEDGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WEST BROADWAY STREET SUITE 310
MISSOULA MT
59802-4012
US

IV. Provider business mailing address

500 WEST BROADWAY STREET SUITE 310
MISSOULA MT
59802-4012
US

V. Phone/Fax

Practice location:
  • Phone: 406-728-6520
  • Fax: 406-329-2936
Mailing address:
  • Phone: 406-728-6520
  • Fax: 406-329-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number355
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMED-PAC-LIC-355
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: