Provider Demographics
NPI:1780777821
Name:MONTGOMERY, JONATHAN RAY (FNP, BC)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:RAY
Last Name:MONTGOMERY
Suffix:
Gender:M
Credentials:FNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14344 CROWN ROSE DR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6927
Mailing Address - Country:US
Mailing Address - Phone:801-302-5976
Mailing Address - Fax:
Practice Address - Street 1:4088 W 1820 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-4801
Practice Address - Country:US
Practice Address - Phone:801-975-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT331062-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily