Provider Demographics
NPI:1134831647
Name:MONTAGUE, NICKOLAS (DPT)
Entity type:Individual
Prefix:DR
First Name:NICKOLAS
Middle Name:
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 S BONITO WAY STE 190
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5618
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:
Practice Address - Street 1:888 SAGE DR STE 102
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-1838
Practice Address - Country:US
Practice Address - Phone:435-233-7006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-15
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13149944-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist