Provider Demographics
NPI:1710901475
Name:FOUNTAIN, TERRY (PA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-1606
Mailing Address - Country:US
Mailing Address - Phone:805-963-2445
Mailing Address - Fax:805-965-6052
Practice Address - Street 1:518 GARDEN ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-1606
Practice Address - Country:US
Practice Address - Phone:805-963-2445
Practice Address - Fax:805-965-6052
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA50918363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA50918Medicaid
CAPA50918Medicare ID - Type Unspecified