=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629819883
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ILIANETTE MONTANEZ PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2024
-----------------------------------------------------
Last Update Date | 06/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5913 WEBB RD
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33615-3219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-210-5616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3129 GRANITE RIDGE LOOP
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34638-6189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-210-5616
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | 9118861
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------