Healthcare Provider Details

I. General information

NPI: 1427983196
Provider Name (Legal Business Name): MONTANA CARTER WOLLENHAUPT PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 W BROAD ST
ATHENS GA
30601-2511
US

IV. Provider business mailing address

340 BEDFORD DR
ATHENS GA
30606-6918
US

V. Phone/Fax

Practice location:
  • Phone: 706-621-7575
  • Fax:
Mailing address:
  • Phone: 770-712-9884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14091
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: