Provider Demographics
NPI:1497159248
Name:MONTANA, JOHN PAUL
Entity type:Individual
Prefix:
First Name:JOHN PAUL
Middle Name:
Last Name:MONTANA
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 1:1313 N MAIZE CT
Mailing Address - Street 2:#208
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-4388
Mailing Address - Country:US
Mailing Address - Phone:316-721-5036
Mailing Address - Fax:
Practice Address - Street 1:1313 N MAIZE CT
Practice Address - Street 2:#208
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4388
Practice Address - Country:US
Practice Address - Phone:316-721-5036
Practice Address - Fax:316-721-1705
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS115011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS115011Medicaid