Provider Demographics
NPI:1619468949
Name:MONTENEGRO, IXCHEL VICTORIA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:IXCHEL
Middle Name:VICTORIA
Last Name:MONTENEGRO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:345 SAINT PAUL ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-2123
Mailing Address - Country:US
Mailing Address - Phone:410-332-9692
Mailing Address - Fax:410-576-5486
Practice Address - Street 1:345 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-2123
Practice Address - Country:US
Practice Address - Phone:410-332-9692
Practice Address - Fax:410-576-5486
Is Sole Proprietor?:No
Enumeration Date:2018-05-22
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0006799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant