Provider Demographics
NPI:1447410980
Name:MONTGOMERY, JASON ROBERT (PAC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ROBERT
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 N COLUMBUS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130
Mailing Address - Country:US
Mailing Address - Phone:740-687-5722
Mailing Address - Fax:740-687-5898
Practice Address - Street 1:2405 N COLUMBUS ST STE 200
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130
Practice Address - Country:US
Practice Address - Phone:740-687-5722
Practice Address - Fax:740-687-5898
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001818363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant