Healthcare Provider Details

I. General information

NPI: 1306052006
Provider Name (Legal Business Name): TARA L. MONTGOMERY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 04/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E. KINCAID STREET
MOUNT VERNON WA
98274-4127
US

IV. Provider business mailing address

1400 E. KINCAID STREET ATTN: CREDENTIALING
MOUNT VERNON WA
98274-4127
US

V. Phone/Fax

Practice location:
  • Phone: 360-428-6434
  • Fax: 360-848-4233
Mailing address:
  • Phone: 360-428-2500
  • Fax: 360-425-6485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOT011765
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOP60329003
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: