Provider Demographics
NPI:1881826675
Name:FORTENBERRY, AARON Q (RPA/RA)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:Q
Last Name:FORTENBERRY
Suffix:
Gender:M
Credentials:RPA/RA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 COUNTY ROAD 2100
Mailing Address - Street 2:
Mailing Address - City:WOODVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75979-3419
Mailing Address - Country:US
Mailing Address - Phone:409-331-9345
Mailing Address - Fax:
Practice Address - Street 1:505 S JOHN REDDITT DR
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3120
Practice Address - Country:US
Practice Address - Phone:936-637-8581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18475243U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant