Provider Demographics
NPI:1508046715
Name:FONTENOT, DUSTIN ALLEN (PA)
Entity Type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:ALLEN
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:970 HESTERS CROSSING RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-8027
Mailing Address - Country:US
Mailing Address - Phone:512-238-0762
Mailing Address - Fax:512-341-7370
Practice Address - Street 1:970 HESTERS CROSSING RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-8027
Practice Address - Country:US
Practice Address - Phone:512-238-0762
Practice Address - Fax:512-341-7370
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y4033OtherBCBS/TX
TXPA05398OtherTEXAS STATE LICENSE
TX8F6696Medicare PIN
TX397126YTS2Medicare PIN