Provider Demographics
NPI:1659083467
Name:MONTGOMERY, JOSHUA (PA-C)
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749495
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9495
Mailing Address - Country:US
Mailing Address - Phone:855-963-2100
Mailing Address - Fax:813-321-1296
Practice Address - Street 1:10750 COLUMBIA PIKE STE 501
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-4460
Practice Address - Country:US
Practice Address - Phone:301-593-9035
Practice Address - Fax:301-593-9035
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-23
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0009392363A00000X
363A00000X
DCPA200001635363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0OtherN/A