Healthcare Provider Details

I. General information

NPI: 1538712583
Provider Name (Legal Business Name): ROBERT MONTGOMERY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2661 COUNTY HIGHWAY I
CHIPPEWA FALLS WI
54729-5407
US

IV. Provider business mailing address

2403 FOLSOM ST
EAU CLAIRE WI
54703-2435
US

V. Phone/Fax

Practice location:
  • Phone: 715-861-0990
  • Fax: 715-861-0274
Mailing address:
  • Phone: 715-552-9784
  • Fax: 715-835-6370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14898
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4811-23
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4811
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: