Provider Demographics
NPI:1104156546
Name:FONTENOT, RYAN P (CRNA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:P
Last Name:FONTENOT
Suffix:
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:BRENHAM
Practice Address - State:TX
Practice Address - Zip Code:77833-5413
Practice Address - Country:US
Practice Address - Phone:979-337-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX789090367500000X
LARN103850367500000X
TXAP119221367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX362797YK6UMedicare PIN