Provider Demographics
NPI:1134962541
Name:BRADY, MONTANA VINCENT
Entity type:Individual
Prefix:
First Name:MONTANA
Middle Name:VINCENT
Last Name:BRADY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4572 VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-8053
Mailing Address - Country:US
Mailing Address - Phone:816-516-1944
Mailing Address - Fax:
Practice Address - Street 1:6304 E 102ND ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-7120
Practice Address - Country:US
Practice Address - Phone:918-850-9488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024021760363LP0808X
OK218275363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health