Provider Demographics
NPI:1508872607
Name:MONTGOMERY, ERIN (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:OSINGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9775 SW WILSHIRE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9775 SW WILSHIRE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5067
Practice Address - Country:US
Practice Address - Phone:503-646-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA155264363AS0400X
WI2000363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42886900Medicaid
WI42886900Medicaid
WI1007 73601Medicare PIN