Provider Demographics
NPI:1881669182
Name:MONTGOMERY, ELLEN M (PA)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 COX RD STE 303
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:757-232-8866
Practice Address - Street 1:2304 W MERCURY BLVD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3115
Practice Address - Country:US
Practice Address - Phone:757-595-9880
Practice Address - Fax:757-595-0362
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840718363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA970000324Medicaid
VAS92801Medicare UPIN
VA970000324Medicaid