Provider Demographics
NPI:1245782416
Name:MONTGOMERY, ERIN J (PA-C)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:J
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:J
Other - Last Name:MURPHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10798 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1329
Mailing Address - Country:US
Mailing Address - Phone:208-377-3368
Mailing Address - Fax:208-322-4691
Practice Address - Street 1:10798 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1329
Practice Address - Country:US
Practice Address - Phone:208-377-3368
Practice Address - Fax:208-322-4691
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1446363AM0700X
ORPA198079363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1245782416Medicaid
OR500762276Medicaid