Provider Demographics
NPI:1548297625
Name:BUNDY-KELM, ANGELA L (PAC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:L
Last Name:BUNDY-KELM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:L
Other - Last Name:BUNDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 35100
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59107-5100
Mailing Address - Country:US
Mailing Address - Phone:406-233-7000
Mailing Address - Fax:
Practice Address - Street 1:620 S HAYNES AVE
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-4769
Practice Address - Country:US
Practice Address - Phone:406-233-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-221363A00000X
MT221363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTM011000377Medicare PIN
MTM011000376Medicare PIN
S88445Medicare UPIN