Healthcare Provider Details

I. General information

NPI: 1215119953
Provider Name (Legal Business Name): JASON T MONTGOMERY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 N 900 W SUITE C
AMERICAN FORK UT
84003-5199
US

IV. Provider business mailing address

PO BOX 8476
BELFAST ME
04915-8476
US

V. Phone/Fax

Practice location:
  • Phone: 801-492-1611
  • Fax: 801-492-1480
Mailing address:
  • Phone: 801-542-8222
  • Fax: 801-542-8227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6743553-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: