Provider Demographics
NPI:1497725717
Name:MONTABAN, AMANDA (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:MONTABAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 N CROATAN HWY
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3990
Mailing Address - Country:US
Mailing Address - Phone:252-261-9211
Mailing Address - Fax:252-261-4329
Practice Address - Street 1:3000 S CROATAN HWY
Practice Address - Street 2:
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-9029
Practice Address - Country:US
Practice Address - Phone:252-441-3507
Practice Address - Fax:252-441-1327
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8089208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211718Medicaid
NCD4924OtherMEDCOST
NC079JXOtherBCBSNC
NC2505819Medicare ID - Type Unspecified