Healthcare Provider Details

I. General information

NPI: 1619468949
Provider Name (Legal Business Name): IXCHEL VICTORIA MONTENEGRO PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2018
Last Update Date: 04/25/2024
Certification Date: 04/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 SAINT PAUL ST
BALTIMORE MD
21202-2123
US

IV. Provider business mailing address

345 SAINT PAUL ST
BALTIMORE MD
21202-2123
US

V. Phone/Fax

Practice location:
  • Phone: 410-332-9692
  • Fax: 410-576-5486
Mailing address:
  • Phone: 410-332-9692
  • Fax: 410-576-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0006799
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: