Provider Demographics
NPI:1699050385
Name:FANTOZZI, CHRISTINA LYNN (PA-C)
Entity type:Individual
Prefix:MS
First Name:CHRISTINA
Middle Name:LYNN
Last Name:FANTOZZI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:FANTOZZI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6511 COYLE AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0306
Practice Address - Country:US
Practice Address - Phone:916-536-3665
Practice Address - Fax:916-536-3593
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21745363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant