Provider Demographics
NPI:1336146539
Name:MONTAQUE, CAROLYN (CRNA)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MONTAQUE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5645 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-5045
Mailing Address - Country:US
Mailing Address - Phone:917-650-1275
Mailing Address - Fax:
Practice Address - Street 1:5645 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:917-650-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY501480367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR5C691Medicare ID - Type Unspecified
NY0422ANMedicare ID - Type Unspecified
NYQ34265Medicare UPIN