Basic Information
| Provider Information | |||||||||
| NPI: | 1609439371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTAG | ||||||||
| FirstName: | MACKENZIE | ||||||||
| MiddleName: | BLAIR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PATTERSON | ||||||||
| OtherFirstName: | MACKENZIE | ||||||||
| OtherMiddleName: | BLAIR | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10465 PARK MEADOWS DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | LONE TREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801245321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037901515 | ||||||||
| FaxNumber: | 3037901989 | ||||||||
| Practice Location | |||||||||
| Address1: | 10465 PARK MEADOWS DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | LONE TREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801245321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037901515 | ||||||||
| FaxNumber: | 3037901989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2019 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | RN.1632920 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.