Provider Demographics
NPI:1063726750
Name:MONTELONGO, MARK DAMON (NP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DAMON
Last Name:MONTELONGO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6901 MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7910
Mailing Address - Country:US
Mailing Address - Phone:254-751-4756
Mailing Address - Fax:
Practice Address - Street 1:6901 MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7910
Practice Address - Country:US
Practice Address - Phone:254-751-4756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX734468363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily