Provider Demographics
NPI:1659923704
Name:MONTGOMERY, COLIN J (PA-C)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:J
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S CLINTON AVE BLDG G2ND
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2668
Mailing Address - Country:US
Mailing Address - Phone:585-341-7685
Mailing Address - Fax:585-341-4220
Practice Address - Street 1:2400 S CLINTON AVE BLDG G2ND
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2668
Practice Address - Country:US
Practice Address - Phone:585-341-7685
Practice Address - Fax:585-341-4220
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23632363AM0700X
NY023632363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical