Provider Demographics
NPI:1316210040
Name:MONTGOMERY, TRAVIS H (PA-C)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:H
Last Name:MONTGOMERY
Suffix:
Gender:M
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 1:222 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1179
Mailing Address - Country:US
Mailing Address - Phone:606-783-6520
Mailing Address - Fax:606-783-6489
Practice Address - Street 1:222 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1179
Practice Address - Country:US
Practice Address - Phone:606-783-6520
Practice Address - Fax:606-783-6489
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1714363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100216070Medicaid