Provider Demographics
NPI:1275582751
Name:FONTANA, PAUL S (ARNP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:FONTANA
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-5250
Mailing Address - Fax:208-625-5251
Practice Address - Street 1:700 W IRONWOOD DR STE 320
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4485
Practice Address - Country:US
Practice Address - Phone:208-625-5250
Practice Address - Fax:208-625-5251
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN34935363L00000X
WARN00161870363L00000X
WAAP30007150363LA2200X
IDNP733A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807415800OtherMEDICAID
WA9648015Medicaid
ID13454103Medicare PIN
S49564Medicare UPIN