Provider Demographics
NPI:1629819883
Name:MONTANEZ, ILIANETTE (PA)
Entity type:Individual
Prefix:
First Name:ILIANETTE
Middle Name:
Last Name:MONTANEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3129 GRANITE RIDGE LOOP
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-6189
Mailing Address - Country:US
Mailing Address - Phone:813-210-5616
Mailing Address - Fax:
Practice Address - Street 1:5913 WEBB RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-3219
Practice Address - Country:US
Practice Address - Phone:813-210-5616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9118861208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology