Provider Demographics
NPI:1588769913
Name:MONTGOMERY, CAROLYN A (PA-C)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:A
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:S
Other - Last Name:AVAU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9555 UPLAND LN N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4485
Mailing Address - Country:US
Mailing Address - Phone:952-993-1440
Mailing Address - Fax:
Practice Address - Street 1:9555 UPLAND LN N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4485
Practice Address - Country:US
Practice Address - Phone:952-993-1440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000785A363A00000X
MN13212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000367990OtherBCBS - MARY STREET
IN000000381096OtherBCBS - GATEWAY
KY95005716Medicaid
KY95005716Medicaid
IN000000381096OtherBCBS - GATEWAY