Provider Demographics
NPI:1730459389
Name:MONTGOMERY, JOLYNN (PA-C)
Entity type:Individual
Prefix:
First Name:JOLYNN
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 E FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-9024
Mailing Address - Country:US
Mailing Address - Phone:800-769-0045
Mailing Address - Fax:
Practice Address - Street 1:2112 E FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-9024
Practice Address - Country:US
Practice Address - Phone:800-769-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1010363A00000X
WA60593479363A00000X
HI673363A00000X
ID1075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant