Provider Demographics
NPI:1003264003
Name:FONTANEZ, RENE JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:RENE
Middle Name:
Last Name:FONTANEZ
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7940 VIA DELLAGIO WAY
Mailing Address - Street 2:142
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-5400
Mailing Address - Country:US
Mailing Address - Phone:407-745-4633
Mailing Address - Fax:407-745-4635
Practice Address - Street 1:7940 VIA DELLAGIO WAY
Practice Address - Street 2:142
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-5400
Practice Address - Country:US
Practice Address - Phone:407-745-4633
Practice Address - Fax:407-745-4635
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 26634225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant