Provider Demographics
NPI:1467424135
Name:MONTGOMERY, WARREN R (PAC)
Entity Type:Individual
Prefix:
First Name:WARREN
Middle Name:R
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:PO BOX 216
Mailing Address - Street 2:
Mailing Address - City:TOWNSHEND
Mailing Address - State:VT
Mailing Address - Zip Code:05353-0216
Mailing Address - Country:US
Mailing Address - Phone:802-365-4331
Mailing Address - Fax:802-365-7384
Practice Address - Street 1:185 GRAFTON ROAD
Practice Address - Street 2:
Practice Address - City:TOWNSHEND
Practice Address - State:VT
Practice Address - Zip Code:05353-0216
Practice Address - Country:US
Practice Address - Phone:802-365-4331
Practice Address - Fax:802-365-7384
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030984363A00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2000356Medicaid
VT2000356Medicaid
S38313Medicare UPIN