Provider Demographics
NPI:1710229737
Name:FONTENOT, ANDREW SR (CRNA)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:FONTENOT
Suffix:SR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 UNION AVE STE 640
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3666
Mailing Address - Country:US
Mailing Address - Phone:901-866-8360
Mailing Address - Fax:901-302-2360
Practice Address - Street 1:877 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2807
Practice Address - Country:US
Practice Address - Phone:901-545-8699
Practice Address - Fax:901-545-8996
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17580367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02636357Medicaid
AR197571001Medicaid
TNQ002094Medicaid
MS02636357Medicaid