Provider Demographics
NPI:1790978617
Name:MONTGOMERY, KEITH ALLEN JR (NP)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:ALLEN
Last Name:MONTGOMERY
Suffix:JR
Gender:M
Credentials:NP
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Mailing Address - Street 1:625 FAIR OAKS AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5801
Mailing Address - Country:US
Mailing Address - Phone:626-346-2455
Mailing Address - Fax:626-639-3005
Practice Address - Street 1:11965 CACTUS RD
Practice Address - Street 2:
Practice Address - City:ADELANTO
Practice Address - State:CA
Practice Address - Zip Code:92301-4906
Practice Address - Country:US
Practice Address - Phone:760-561-6081
Practice Address - Fax:877-778-9461
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2018-07-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA758758163WM0705X
CA95008198363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical