MEDICARE: DR. NICHOLAS ALAN MANTINI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204R00000X	Electrodiagnostic Medicine Physician	MED-PHYS-LIC-86861	MT
2	207RC0001X	Clinical Cardiac Electrophysiology Physician	MED-PHYS-LIC-86861	MT

General Provider Information

NPI Number	:	1588808646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICHOLAS ALAN MANTINI

Provider Business Mailing Address
First Line	:	PO BOX 31001
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91110-4114
Country	:	US
Telephone Number	:	406-329-5615
Fax Number	:	406-329-5606

Provider Business Practice Location Address
First Line	:	500 W BROADWAY ST STE 320
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59802-4003
Country	:	US
Telephone Number	:	406-329-5615
Fax Number	:	406-329-5606

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2009
Last Update Date	:	01/15/2026

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