Healthcare Provider Details

I. General information

NPI: 1306141213
Provider Name (Legal Business Name): FREDDY L MONTENEGRO NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2011
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 E SOUTHERN AVE STE 103
MESA AZ
85204
US

IV. Provider business mailing address

1533 E WILLETTA ST
PHOENIX AZ
85006-2935
US

V. Phone/Fax

Practice location:
  • Phone: 602-569-3999
  • Fax: 602-569-3887
Mailing address:
  • Phone: 602-569-3999
  • Fax: 602-569-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19900
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP5467
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number19900
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: