Provider Demographics
NPI:1710347901
Name:MONTGOMERY, SHANON DAVID (NP)
Entity Type:Individual
Prefix:
First Name:SHANON
Middle Name:DAVID
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:440 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4631
Practice Address - Country:US
Practice Address - Phone:906-776-9040
Practice Address - Fax:906-774-7279
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704217286363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AG0216095OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS