Provider Demographics
NPI:1053372821
Name:SOULE, MOZELLE M (PA-C)
Entity type:Individual
Prefix:
First Name:MOZELLE
Middle Name:M
Last Name:SOULE
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 HIGHLAND BLVD
Mailing Address - Street 2:ATTN PFS CREDENTIALING
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6902
Mailing Address - Country:US
Mailing Address - Phone:406-414-5000
Mailing Address - Fax:
Practice Address - Street 1:937 HIGHLAND BLVD STE 5510
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6916
Practice Address - Country:US
Practice Address - Phone:406-414-3959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT15524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1053372821Medicaid
MAAP2151Medicare ID - Type Unspecified