Provider Demographics
NPI:1063238491
Name:MONTY, MADISON RAE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:RAE
Last Name:MONTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7017 S BUFFALO DR APT 2179
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-4101
Mailing Address - Country:US
Mailing Address - Phone:480-398-6933
Mailing Address - Fax:
Practice Address - Street 1:3196 S MARYLAND PKWY STE 208
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-2313
Practice Address - Country:US
Practice Address - Phone:702-796-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant