Healthcare Provider Details

I. General information

NPI: 1467424135
Provider Name (Legal Business Name): WARREN R MONTGOMERY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 GRAFTON ROAD
TOWNSHEND VT
05353-0216
US

IV. Provider business mailing address

PO BOX 216
TOWNSHEND VT
05353-0216
US

V. Phone/Fax

Practice location:
  • Phone: 802-365-4331
  • Fax: 802-365-7384
Mailing address:
  • Phone: 802-365-4331
  • Fax: 802-365-7384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055-0030984
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: