Provider Demographics
NPI:1407024052
Name:FONSECA, GUILLERMO ROBERTO (LSA)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:ROBERTO
Last Name:FONSECA
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5600 SAINT MORITZ ST
Mailing Address - Street 2:
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401-2617
Mailing Address - Country:US
Mailing Address - Phone:832-646-8021
Mailing Address - Fax:
Practice Address - Street 1:5600 SAINT MORITZ ST
Practice Address - Street 2:
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-2617
Practice Address - Country:US
Practice Address - Phone:832-646-8021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-18
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00378246ZC0007X, 246ZS0410X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist