Provider Demographics
NPI:1770920621
Name:MONTGOMERY, JUSTIN A (NP)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:A
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:105 W STONE DR
Mailing Address - Street 2:SUITE 6A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3365
Mailing Address - Country:US
Mailing Address - Phone:423-408-7220
Mailing Address - Fax:423-408-7405
Practice Address - Street 1:378 MARKETPLACE DR
Practice Address - Street 2:SUITE 5
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2361
Practice Address - Country:US
Practice Address - Phone:423-282-0751
Practice Address - Fax:423-282-1577
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2015-06-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN17660363LF0000X
VA0024170905363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVA338BMedicare PIN
TN103I506090Medicare PIN