Provider Demographics
NPI:1235327974
Name:MONTAGUE, GARY PAUL
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:PAUL
Last Name:MONTAGUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GARY
Other - Middle Name:P
Other - Last Name:MONTAGUE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:P.O. BOX 173894
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3894
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1100 BALSAM AVENUE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3404
Practice Address - Country:US
Practice Address - Phone:303-440-2037
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA2507363A00000X
COPA.0002507363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32372736Medicaid
CO32372736Medicaid