Provider Demographics
NPI:1740513563
Name:MONTGOMERY, JUSTINE C (PA)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:C
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:C
Other - Last Name:HORNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:136 S PINE AVE
Mailing Address - City:STOYSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15563-6002
Mailing Address - Country:US
Mailing Address - Phone:814-893-5568
Mailing Address - Fax:814-893-5989
Practice Address - Street 1:430 STONYCREEK ST
Practice Address - Street 2:
Practice Address - City:BOSWELL
Practice Address - State:PA
Practice Address - Zip Code:15531-1024
Practice Address - Country:US
Practice Address - Phone:814-629-5612
Practice Address - Fax:814-629-7199
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053952363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031963260001Medicaid
PA393820Medicare PIN
PA164253EWSMedicare PIN
PA069206Medicare PIN