Provider Demographics
NPI:1376223818
Name:MONTGOMERY, BLAKE WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:WILLIAM
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 1:1681 W 3860 S STE 106B
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-6274
Mailing Address - Country:US
Mailing Address - Phone:385-429-0785
Mailing Address - Fax:
Practice Address - Street 1:1681 W 3860 S STE 106B
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84119-6274
Practice Address - Country:US
Practice Address - Phone:385-429-0785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8747490-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant