Provider Demographics
NPI:1609474428
Name:FONTENOT, THEA CHRISTINE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:THEA
Middle Name:CHRISTINE
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 OAK PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8911
Mailing Address - Country:US
Mailing Address - Phone:337-494-3038
Mailing Address - Fax:
Practice Address - Street 1:1701 OAK PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8911
Practice Address - Country:US
Practice Address - Phone:337-494-3830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA324688363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty