Healthcare Provider Details

I. General information

NPI: 1104835594
Provider Name (Legal Business Name): JASON MONTGOMERY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 10/20/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3750 N BRIARWOOD LN
MUNCIE IN
47304
US

IV. Provider business mailing address

3750 N BRIARWOOD LN
MUNCIE IN
47304
US

V. Phone/Fax

Practice location:
  • Phone: 765-213-6373
  • Fax:
Mailing address:
  • Phone: 765-213-6373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000879A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3167
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: