Healthcare Provider Details

I. General information

NPI: 1548454820
Provider Name (Legal Business Name): BRYN MONTALVO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRYN FURLONG PA-C

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 S WADSWORTH BLVD
LAKEWOOD CO
80232-5406
US

IV. Provider business mailing address

3701 S BROADWAY
ENGLEWOOD CO
80113-3611
US

V. Phone/Fax

Practice location:
  • Phone: 303-985-4832
  • Fax: 303-985-4851
Mailing address:
  • Phone: 303-360-6276
  • Fax: 303-467-5355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMF1392430
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004495
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: