Provider Demographics
NPI:1952390353
Name:MONTGOMERY, JEREMIAH R (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:R
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 1:2604 MEDICAL OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-9417
Mailing Address - Country:US
Mailing Address - Phone:919-580-0004
Mailing Address - Fax:919-580-9099
Practice Address - Street 1:2604 MEDICAL OFFICE PL
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9417
Practice Address - Country:US
Practice Address - Phone:919-580-0004
Practice Address - Fax:919-580-9099
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103911363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q01227OtherUPIN
NC103911OtherLICENSE
NC103911OtherLICENSE
2759928Medicare UPIN