Provider Demographics
NPI:1073591103
Name:FONTANA, KRISTINA (M A)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:FONTANA
Suffix:
Gender:F
Credentials:M A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2040 W CHARLESTON BLVD
Mailing Address - Street 2:202-A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2227
Mailing Address - Country:US
Mailing Address - Phone:702-671-2355
Mailing Address - Fax:702-382-5388
Practice Address - Street 1:2040 W CHARLESTON BLVD
Practice Address - Street 2:401
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2227
Practice Address - Country:US
Practice Address - Phone:702-671-2200
Practice Address - Fax:702-385-7719
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
NEWQBHVMedicare ID - Type UnspecifiedGROUP MEDICARE