Basic Information
| Provider Information | |||||||||
| NPI: | 1790978617 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 FAIR OAKS AVE STE 270 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910305801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263462455 | ||||||||
| FaxNumber: | 6266393005 | ||||||||
| Practice Location | |||||||||
| Address1: | 11965 CACTUS RD | ||||||||
| Address2: | |||||||||
| City: | ADELANTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923014906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605616081 | ||||||||
| FaxNumber: | 8777789461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2007 | ||||||||
| LastUpdateDate: | 07/12/2018 | ||||||||
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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 | 163WM0705X | 758758 | CA | N | Nursing Service Providers | Registered Nurse | Medical-Surgical | 363L00000X | 95008198 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.