Provider Demographics
NPI:1366490005
Name:MONTGOMERY-JOHNSON, TARA LYN (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYN
Last Name:MONTGOMERY-JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:LYN
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:41850 W 11 MILE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1857
Mailing Address - Country:US
Mailing Address - Phone:248-860-4634
Mailing Address - Fax:
Practice Address - Street 1:90 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1527
Practice Address - Country:US
Practice Address - Phone:248-860-4634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004621363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP02040005Medicare ID - Type Unspecified
P02040005Medicare UPIN