Provider Demographics
NPI:1770590952
Name:FONTAINE, CARRIE E (PA)
Entity type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:E
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 E UNIVERSITY DR STE 240
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-8309
Mailing Address - Country:US
Mailing Address - Phone:480-999-7911
Mailing Address - Fax:
Practice Address - Street 1:1901 E UNIVERSITY DR STE 240
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-8309
Practice Address - Country:US
Practice Address - Phone:480-999-7911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2025-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0775363A00000X
AZ9689363AM0700X
MEPA-658363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30338184Medicaid
NHAP119603Medicare PIN
NH30338184Medicaid