Provider Demographics
NPI:1710958061
Name:MONTANO, LAURIE (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:MONTANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4048 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5391
Mailing Address - Country:US
Mailing Address - Phone:907-770-7800
Mailing Address - Fax:907-929-4660
Practice Address - Street 1:4048 LAUREL ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5333
Practice Address - Country:US
Practice Address - Phone:907-770-7800
Practice Address - Fax:907-929-4660
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4970174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK710889996OtherTAX ID NUMBER
AKK152174Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID