Provider Demographics
NPI:1720553324
Name:MONTENEGRO, RICHARD CHRISTIAN (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CHRISTIAN
Last Name:MONTENEGRO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2621 S 3270 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1119
Mailing Address - Country:US
Mailing Address - Phone:385-261-2737
Mailing Address - Fax:801-746-0420
Practice Address - Street 1:1388 S NAVAJO ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-3493
Practice Address - Country:US
Practice Address - Phone:801-955-2360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0248578OtherSTUDENT ID