Provider Demographics
NPI:1215134440
Name:SEYMOUR, MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:SEYMOUR
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 FALLS LOOP
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59912-4513
Mailing Address - Country:US
Mailing Address - Phone:406-755-0811
Mailing Address - Fax:
Practice Address - Street 1:PRB 9, SPINE ROAD DROP POINT 51
Practice Address - Street 2:
Practice Address - City:PRUDHOE BAY
Practice Address - State:AK
Practice Address - Zip Code:99734
Practice Address - Country:US
Practice Address - Phone:907-659-5239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1814363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8442238Medicaid
WA8442238Medicaid
WA8857466Medicare PIN