Provider Demographics
NPI:1952382590
Name:MONTGOMERY, PAULA JEAN (PHYSICIAN ASSOCIATE)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:JEAN
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PHYSICIAN ASSOCIATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 W MEMORIAL RD
Mailing Address - Street 2:PLAZA 308
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8366
Mailing Address - Country:US
Mailing Address - Phone:405-749-7031
Mailing Address - Fax:405-749-7036
Practice Address - Street 1:4140 W MEMORIAL RD
Practice Address - Street 2:PLAZA 308
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8366
Practice Address - Country:US
Practice Address - Phone:405-749-7031
Practice Address - Fax:405-749-7036
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA175363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R01377Medicare UPIN
1952382590Medicare PIN