Provider Demographics
NPI:1104835594
Name:MONTGOMERY, JASON (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
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 1:3750 N BRIARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304
Mailing Address - Country:US
Mailing Address - Phone:765-213-6373
Mailing Address - Fax:
Practice Address - Street 1:3750 N BRIARWOOD LN
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304
Practice Address - Country:US
Practice Address - Phone:765-213-6373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000879A363A00000X
CO3167363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant