Provider Demographics
NPI:1871609693
Name:MONTGOMERY, PATRICIA LEE (PA-C)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LEE
Last Name:MONTGOMERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:LEE
Other - Last Name:RARDIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1005 HEALTH CENTER DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938
Mailing Address - Country:US
Mailing Address - Phone:217-258-4051
Mailing Address - Fax:217-258-4063
Practice Address - Street 1:606 MAIN ST
Practice Address - Street 2:
Practice Address - City:BAYBORO
Practice Address - State:NC
Practice Address - Zip Code:28515
Practice Address - Country:US
Practice Address - Phone:252-745-3191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001309363A00000X
NC0010-06097363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL77018Medicare PIN