Provider Demographics
NPI:1306141213
Name:MONTENEGRO, FREDDY L (NP)
Entity type:Individual
Prefix:
First Name:FREDDY
Middle Name:L
Last Name:MONTENEGRO
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 1:1533 E WILLETTA ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2935
Mailing Address - Country:US
Mailing Address - Phone:602-569-3999
Mailing Address - Fax:602-569-3887
Practice Address - Street 1:616 E SOUTHERN AVE STE 103
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204
Practice Address - Country:US
Practice Address - Phone:602-569-3999
Practice Address - Fax:602-569-3887
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19900363LF0000X, 363L00000X
AZAP5467363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ890635Medicaid