Provider Demographics
NPI:1578558961
Name:FONTENOT, THERESA M (PAC)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:M
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 TEXAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3207
Mailing Address - Country:US
Mailing Address - Phone:903-255-6398
Mailing Address - Fax:903-794-6305
Practice Address - Street 1:3939 TEXAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3207
Practice Address - Country:US
Practice Address - Phone:903-255-6398
Practice Address - Fax:903-794-6305
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4995690001OtherCIGNA GOVERNMENT SERVICES
R64719Medicare UPIN
8B4007Medicare PIN