Provider Demographics
NPI:1366811606
Name:MONTAGUE, BLAINE K (PA)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:K
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 E MARKETPLACE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-2060
Mailing Address - Country:US
Mailing Address - Phone:801-717-0341
Mailing Address - Fax:
Practice Address - Street 1:819 E MARKETPLACE DRIVE
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-2060
Practice Address - Country:US
Practice Address - Phone:801-717-0341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9508541-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant