Provider Demographics
NPI:1275927857
Name:MONTGOMERY, ROY (PA-C)
Entity Type:Individual
Prefix:
First Name:ROY
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 1:4600 S MILL AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-6757
Mailing Address - Country:US
Mailing Address - Phone:480-305-2888
Mailing Address - Fax:
Practice Address - Street 1:1750 E ARICA RD
Practice Address - Street 2:
Practice Address - City:ELOY
Practice Address - State:AZ
Practice Address - Zip Code:85131
Practice Address - Country:US
Practice Address - Phone:801-243-3675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant