Basic Information
| Provider Information | |||||||||
| NPI: | 1043501778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | BERNARD | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL DR | ||||||||
| Address2: | ATTN CENTERS FOR HEALTHY AGING | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036505000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL DR | ||||||||
| Address2: | ATTN CENTERS FOR HEALTHY AGING | ||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037561000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036505000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2011 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 052034-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1019890 | 05 | VT | MEDICAID | 3082773 | 05 | NH | MEDICAID |