Provider Demographics
NPI:1043825854
Name:MCCOY, MONTY PAUL
Entity Type:Individual
Prefix:
First Name:MONTY
Middle Name:PAUL
Last Name:MCCOY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 MATTINO WAY
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-1434
Mailing Address - Country:US
Mailing Address - Phone:702-806-7028
Mailing Address - Fax:443-596-1281
Practice Address - Street 1:264 MATTINO WAY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-1434
Practice Address - Country:US
Practice Address - Phone:702-806-7028
Practice Address - Fax:443-596-1281
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1568831147Medicaid