MEDICARE: PAULA JEAN MONTGOMERY PHYSICIAN ASSOCIATE

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	363A00000X	Physician Assistant	PA175	OK

General Provider Information

NPI Number	:	1952382590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULA JEAN MONTGOMERY PHYSICIAN ASSOCIATE

Provider Business Mailing Address
First Line	:	4140 W MEMORIAL RD
Second Line	:	PLAZA 308
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-8366
Country	:	US
Telephone Number	:	405-749-7031
Fax Number	:	405-749-7036

Provider Business Practice Location Address
First Line	:	4140 W MEMORIAL RD
Second Line	:	PLAZA 308
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-8366
Country	:	US
Telephone Number	:	405-749-7031
Fax Number	:	405-749-7036

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

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	07/23/2007

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