Basic Information
| Provider Information | |||||||||
| NPI: | 1447858725 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTELLA | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 W GERMANTOWN PIKE STE 150 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194621062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105263000 | ||||||||
| FaxNumber: | 5177872922 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E LANCASTER AVE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190963450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105263000 | ||||||||
| FaxNumber: | 5177872922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2020 | ||||||||
| LastUpdateDate: | 01/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN626765 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | RN626765 | 01 | PA | RN LICENSE | OTHER |