Provider Demographics
NPI:1679582936
Name:MONTAGUE, MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MONTAGUE
Suffix:
Gender:F
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 1:107 COLUMBINE DR
Mailing Address - Street 2:
Mailing Address - City:WEST GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19390-1354
Mailing Address - Country:US
Mailing Address - Phone:610-202-6899
Mailing Address - Fax:
Practice Address - Street 1:2021B EMMORTON RD STE 210
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-8972
Practice Address - Country:US
Practice Address - Phone:410-569-1001
Practice Address - Fax:410-569-1569
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000418363AM0700X
MDC0005669363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical