Provider Demographics
NPI:1104966506
Name:FONTANILLA, ROGELIO BILL (CRNA)
Entity type:Individual
Prefix:
First Name:ROGELIO
Middle Name:BILL
Last Name:FONTANILLA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5302
Mailing Address - Country:US
Mailing Address - Phone:409-772-2222
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-5302
Practice Address - Country:US
Practice Address - Phone:409-772-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX610236367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX760010407OtherEIN
TXP00412655Medicare PIN
TX8J6655Medicare PIN
TXCG0510Medicare PIN
TX00R518Medicare PIN