Basic Information
| Provider Information | |||||||||
| NPI: | 1467424135 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONTGOMERY | ||||||||
| FirstName: | WARREN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 216 | ||||||||
| Address2: | |||||||||
| City: | TOWNSHEND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053530216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023654331 | ||||||||
| FaxNumber: | 8023657384 | ||||||||
| Practice Location | |||||||||
| Address1: | 185 GRAFTON ROAD | ||||||||
| Address2: | |||||||||
| City: | TOWNSHEND | ||||||||
| State: | VT | ||||||||
| PostalCode: | 053530216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8023654331 | ||||||||
| FaxNumber: | 8023657384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 01/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 055-0030984 | VT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2000356 | 05 | VT | MEDICAID |