Provider Demographics
NPI:1700842846
Name:MONTOYA, NICOLE R (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:MONTOYA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 E BASELINE RD STE 107
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2744
Mailing Address - Country:US
Mailing Address - Phone:480-374-7354
Mailing Address - Fax:480-371-1121
Practice Address - Street 1:4001 E BASELINE RD STE 107
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:480-374-7354
Practice Address - Fax:480-371-1121
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant