Basic Information
| Provider Information | |||||||||
| NPI: | 1760764054 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKOVLY | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 HIGHLAND BLVD | ||||||||
| Address2: | ATTN PFS CREDENTIALING | ||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597156902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064145000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 BOBCAT CIRCLE | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597153380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064144780 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2011 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 65940 | MT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1760764054 | 05 | MT | MEDICAID |