Healthcare Provider Details

I. General information

NPI: 1972704211
Provider Name (Legal Business Name): MONTSHO PILI CORPPETTS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 S DIVISION ST SUITE 2
SPOKANE WA
99202-1331
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 509-474-5858
  • Fax: 509-474-5859
Mailing address:
  • Phone: 866-747-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60607471
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: