Provider Demographics
NPI:1558024638
Name:FONTENETTE, CHARLES NATHANIEL JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:NATHANIEL
Last Name:FONTENETTE
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 JUNELL ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77088-6300
Mailing Address - Country:US
Mailing Address - Phone:832-545-0977
Mailing Address - Fax:
Practice Address - Street 1:11001 CRESCENT MOON DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77064-4024
Practice Address - Country:US
Practice Address - Phone:281-477-8877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2029932208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation