Provider Demographics
NPI:1902913726
Name:FONTENOT, THOMAS J (CRNA)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:FONTENOT
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 1:202 RUE BORDEAUX
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-4328
Mailing Address - Country:US
Mailing Address - Phone:337-298-5937
Mailing Address - Fax:
Practice Address - Street 1:202 RUE BORDEAUX
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520-4328
Practice Address - Country:US
Practice Address - Phone:337-298-5937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN065361367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1654574Medicaid
5T644Medicare ID - Type Unspecified