Provider Demographics
NPI:1780734442
Name:MONTES, GREGORY A (PA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:MONTES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-0277
Mailing Address - Country:US
Mailing Address - Phone:718-926-5854
Mailing Address - Fax:
Practice Address - Street 1:330 EAST 17TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-420-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ66605Medicare UPIN
NY6175L1Medicare ID - Type Unspecified