Provider Demographics
NPI:1700766292
Name:MONTGOMERY, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11616 N 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68112-1147
Mailing Address - Country:US
Mailing Address - Phone:319-389-4505
Mailing Address - Fax:
Practice Address - Street 1:11616 N 34TH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68112-1147
Practice Address - Country:US
Practice Address - Phone:319-389-4505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver