Provider Demographics
NPI:1639253347
Name:MONTGOMERY, LISA (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3309 S 750 W
Mailing Address - Street 2:
Mailing Address - City:RUSSIAVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46979-9146
Mailing Address - Country:US
Mailing Address - Phone:765-883-2273
Mailing Address - Fax:
Practice Address - Street 1:3309 S 750 W
Practice Address - Street 2:
Practice Address - City:RUSSIAVILLE
Practice Address - State:IN
Practice Address - Zip Code:46979-9146
Practice Address - Country:US
Practice Address - Phone:765-883-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000327363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970014767Medicare PIN
IN151560I9Medicare PIN
IN191630CCMedicare PIN
INS61080Medicare UPIN
IN151990RMedicare PIN