Provider Demographics
NPI:1184005258
Name:FONTANILLA, ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FONTANILLA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69175 RAMON RD
Mailing Address - Street 2:BUILDING A
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-3344
Mailing Address - Country:US
Mailing Address - Phone:760-321-6776
Mailing Address - Fax:760-321-4036
Practice Address - Street 1:69175 RAMON RD
Practice Address - Street 2:BUILDING A
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-3344
Practice Address - Country:US
Practice Address - Phone:760-321-6776
Practice Address - Fax:760-321-4036
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52552363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant