Basic Information
| Provider Information | |||||||||
| NPI: | 1114906658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PALEN | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 25TH ST S | ||||||||
| Address2: | |||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594055183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067318888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1401 25TH ST S | ||||||||
| Address2: | |||||||||
| City: | GREAT FALLS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594055183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4067318888 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 43108 | MT | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 350306 | 05 | AZ | MEDICAID |