Provider Demographics
NPI:1639860539
Name:MONTGOMERY, ABIGAIL LYN
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:LYN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
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 1289
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33601-1289
Mailing Address - Country:US
Mailing Address - Phone:813-251-0793
Mailing Address - Fax:813-844-1988
Practice Address - Street 1:5 TAMPA GENERAL CIR STE 300
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3578
Practice Address - Country:US
Practice Address - Phone:813-251-0793
Practice Address - Fax:813-844-1688
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117641363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant