Provider Demographics
NPI:1114727153
Name:MONTGOMERY, MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 SOUTHPOINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8203
Mailing Address - Country:US
Mailing Address - Phone:904-634-0640
Mailing Address - Fax:904-634-0203
Practice Address - Street 1:45 GROOVER LOOP STE 201
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6586
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant