Provider Demographics
NPI:1679533590
Name:FONTANA, CHAD RYAN (PA)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:RYAN
Last Name:FONTANA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6818 AUSTIN CENTER BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3100
Mailing Address - Country:US
Mailing Address - Phone:512-856-1000
Mailing Address - Fax:
Practice Address - Street 1:6818 AUSTIN CENTER BLVD STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3100
Practice Address - Country:US
Practice Address - Phone:512-856-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02691363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP05935Medicare UPIN
TX85N550Medicare ID - Type Unspecified
TX970022848Medicare ID - Type Unspecified
TX84N971Medicare ID - Type Unspecified
TX970017624Medicare ID - Type Unspecified