Provider Demographics
NPI:1760092340
Name:MONTGOMERY, LARRY ALLEN (MSN, APRN, AGNP-C)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ALLEN
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:MSN, APRN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:866 ORANGE TER
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2151
Mailing Address - Country:US
Mailing Address - Phone:478-246-1114
Mailing Address - Fax:478-202-2488
Practice Address - Street 1:3780 EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-0800
Practice Address - Country:US
Practice Address - Phone:478-633-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333300000X
GAGAA-NP001276363LA2200X
DCNP500008018363LA2200X
OK211116363LA2200X
FL11024684363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No333300000XSuppliersEmergency Response System Companies