Healthcare Provider Details

I. General information

NPI: 1225303159
Provider Name (Legal Business Name): TAYLOR M LIES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2012
Last Update Date: 11/27/2023
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 RIDGEWATER DR STE A
POLSON MT
59860-8977
US

IV. Provider business mailing address

106 RIDGEWATER DR STE A
POLSON MT
59860-8977
US

V. Phone/Fax

Practice location:
  • Phone: 406-883-3200
  • Fax: 406-883-9483
Mailing address:
  • Phone: 406-883-3200
  • Fax: 406-883-9483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number15504
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: