Provider Demographics
NPI:1396176293
Name:MONTGOMERY, AIMEE
Entity type:Individual
Prefix:
First Name:AIMEE
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 GRANBURY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-5912
Mailing Address - Country:US
Mailing Address - Phone:817-346-1925
Mailing Address - Fax:817-292-7237
Practice Address - Street 1:7001 GRANBURY RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-5912
Practice Address - Country:US
Practice Address - Phone:817-346-1925
Practice Address - Fax:817-292-7237
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08762363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX332534201Medicaid
TX328674YKPWMedicare PIN