Healthcare Provider Details

I. General information

NPI: 1164798542
Provider Name (Legal Business Name): PAMELA S CANON ACUPUNCTURIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 09/04/2023
Certification Date: 09/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 1ST AVE W
ROUNDUP MT
59072-2808
US

IV. Provider business mailing address

20 1ST AVE W PO BOX 904
ROUNDUP MT
59072-2808
US

V. Phone/Fax

Practice location:
  • Phone: 406-208-0280
  • Fax: 406-969-1241
Mailing address:
  • Phone: 406-208-0280
  • Fax: 844-442-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberMED-ACU-LIC-170
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: