Provider Demographics
NPI:1720082209
Name:MONTOYA-CHICK, MARIAN N (APRN-BC)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:N
Last Name:MONTOYA-CHICK
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 BREN RD E
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9664
Mailing Address - Country:US
Mailing Address - Phone:541-969-5954
Mailing Address - Fax:
Practice Address - Street 1:3627 SE DOCKSIDE DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-9346
Practice Address - Country:US
Practice Address - Phone:541-969-5954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201707820NP-PP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX042592802Medicaid
TX88096HMedicare PIN
TX042592802Medicaid