Basic Information
| Provider Information | |||||||||
| NPI: | 1366690265 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | NATHAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2716 ASHTON DRIVE | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284122489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103323800 | ||||||||
| FaxNumber: | 9102510421 | ||||||||
| Practice Location | |||||||||
| Address1: | 3787 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036148 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103323800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2008 | ||||||||
| LastUpdateDate: | 10/22/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SL008853 | PA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 363AM0700X | 0010-03954 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 001003954 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.