Provider Demographics
NPI:1366690265
Name:MONTGOMERY, NATHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:NATHAN
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 1:2716 ASHTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2489
Mailing Address - Country:US
Mailing Address - Phone:910-332-3800
Mailing Address - Fax:910-251-0421
Practice Address - Street 1:3787 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6148
Practice Address - Country:US
Practice Address - Phone:910-332-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL008853235Z00000X
NC0010-03954363AM0700X
NC001003954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical