MEDICARE: MR. JONATHAN RAY MONTGOMERY FNP, BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	331062-4405	UT

General Provider Information

NPI Number	:	1780777821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN RAY MONTGOMERY FNP, BC

Provider Business Mailing Address
First Line	:	14344 CROWN ROSE DR
Second Line	:
City	:	HERRIMAN
State	:	UT
Zip	:	84096-6927
Country	:	US
Telephone Number	:	801-302-5976
Fax Number	:

Provider Business Practice Location Address
First Line	:	4088 W 1820 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104-4801
Country	:	US
Telephone Number	:	801-975-7799
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	12/29/2008

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