Provider Demographics
NPI:1194788323
Name:MONTOYA, JERRY R (PA-C)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:R
Last Name:MONTOYA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:HC 66-196-3
Mailing Address - Street 2:
Mailing Address - City:MOUNTAINAIR
Mailing Address - State:NM
Mailing Address - Zip Code:87036
Mailing Address - Country:US
Mailing Address - Phone:505-265-1711
Mailing Address - Fax:505-256-2747
Practice Address - Street 1:1501 SAN PEDRO SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-9874
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:505-256-2747
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM80-PA011363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical